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89-608 PS 2004

H.R. 151 AND H.R. 2440

LEGISLATIVE HEARING

BEFORE THE

COMMITTEE ON RESOURCES 

U.S. HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

Wednesday, October 1, 2003

Serial No. 108-64

Printed for the use of the Committee on Resources

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/house 

or 

Committee address: http://resourcescommittee.house.gov 

(II)

COMMITTEE ON RESOURCES 

RICHARD W. POMBO, California, Chairman 

NICK J. RAHALL II, West Virginia, Ranking Democrat Member

Don Young, Alaska 

W.J. ‘‘Billy’’ Tauzin, Louisiana 

Jim Saxton, New Jersey 

Elton Gallegly, California 

John J. Duncan, Jr., Tennessee 

Wayne T. Gilchrest, Maryland 

Ken Calvert, California 

Scott McInnis, Colorado 

Barbara Cubin, Wyoming 

George Radanovich, California 

Walter B. Jones, Jr., North Carolina 

Chris Cannon, Utah 

John E. Peterson, Pennsylvania 

Jim Gibbons, Nevada, 

Vice Chairman 

Mark E. Souder, Indiana 

Greg Walden, Oregon 

Thomas G. Tancredo, Colorado 

J.D. Hayworth, Arizona 

Tom Osborne, Nebraska 

Jeff Flake, Arizona 

Dennis R. Rehberg, Montana 

Rick Renzi, Arizona 

Tom Cole, Oklahoma 

Stevan Pearce, New Mexico 

Rob Bishop, Utah 

Devin Nunes, California 

Randy Neugebauer, Texas 

Dale E. Kildee, Michigan 

Eni F.H. Faleomavaega, American Samoa 

Neil Abercrombie, Hawaii 

Solomon P. Ortiz, Texas 

Frank Pallone, Jr., New Jersey 

Calvin M. Dooley, California 

Donna M. Christensen, Virgin Islands 

Ron Kind, Wisconsin 

Jay Inslee, Washington 

Grace F. Napolitano, California 

Tom Udall, New Mexico 

Mark Udall, Colorado 

Anı ́bal Acevedo-Vila ́, Puerto Rico 

Brad Carson, Oklahoma 

Rau ́l M. Grijalva, Arizona 

Dennis A. Cardoza, California 

Madeleine Z. Bordallo, Guam 

George Miller, California 

Edward J. Markey, Massachusetts 

Rube ́n Hinojosa, Texas 

Ciro D. Rodriguez, Texas 

Joe Baca, California 

Betty McCollum, Minnesota

Steven J. Ding, Chief of Staff 

Lisa Pittman, Chief Counsel 

James H. Zoia, Democrat Staff Director 

Jeffrey P. Petrich, Democrat Chief Counsel 

(III)

C O N T E N T S 

Page

Hearing held on Wednesday, October 1, 2003 ....................................................... 1

Statement of Members: 

Carson, Hon. Brad, a Representative in Congress from the State of 

Oklahoma, Prepared statement on H.R. 151 and H.R. 2440 ................... 5

Kildee, Hon. Dale, a Representative in Congress from the State of 

Michigan, Prepared statement on H.R. 151 and H.R. 2440 .................... 5

Nethercutt, Hon. George R., Jr., a Representative in Congress from the 

State of Washington ..................................................................................... 6

Prepared statement on H.R. 151 ............................................................. 7

Pombo, Hon. Richard W., a Representative in Congress from the State 

of California ................................................................................................... 1

Prepared statement on H.R. 151 and H.R. 2440 ................................... 2

Rahall, Hon. Nick J., II, a Representative in Congress from the State 

of West Virginia ........................................................................................... 3

Prepared statement on H.R. 151 and H.R. 2440 ................................... 4

Udall. Hon. Tom, a Representative in Congress from the State of 

New Mexico, Prepared statement on H.R. 2440 ....................................... 58

Statement of Witnesses: 

Davis-Wheeler, Julia, Co-Chair, National Indian Health Board .................. 39

Prepared statement on H.R. 151 and H.R. 2440 ................................... 41

Hunter, Anthony, Board President, National Council of Urban Indian 

Health ............................................................................................................ 31

Prepared statement on H.R. 151 and H.R. 2440 ................................... 33

Lincoln, Michel, Deputy Director, Indian Health Service ............................. 12

Prepared statement on H.R. 2440 ........................................................... 14

Shirley, Joe, Jr., President, Navajo Nation .................................................... 25

Prepared statement on H.R. 151 and H.R. 2440 ................................... 27

(1)

LEGISLATIVE HEARING ON H.R. 151, TO 

ELEVATE THE POSITION OF DIRECTOR OF 

THE INDIAN HEALTH SERVICE WITHIN THE 

DEPARTMENT OF HEALTH AND HUMAN 

SERVICES TO ASSISTANT SECRETARY FOR 

INDIAN HEALTH, AND FOR OTHER PURPOSES; AND H.R. 2440, TO IMPROVE THE IMPLEMENTATION OF THE FEDERAL RESPONSIBILITY FOR THE CARE AND EDUCATION 

OF INDIAN PEOPLE BY IMPROVING THE 

SERVICES AND FACILITIES OF FEDERAL 

HEALTH PROGRAMS FOR INDIANS AND 

ENCOURAGING MAXIMUM PARTICIPATION 

OF INDIANS IN SUCH PROGRAMS, AND FOR 

OTHER PURPOSES. (INDIAN HEALTH CARE 

IMPROVEMENT ACT AMENDMENTS OF 2003) 

Wednesday, October 1, 2003

U.S. House of Representatives 

Committee on Resources 

Washington, DC 

The Committee met, pursuant to notice, at 10:20 a.m., in Room 

1324, Longworth House Office Building, Hon. Richard Pombo 

[Chairman of the Committee] presiding. 

Present: Representatives Pombo [The Chairman] Gibbons, 

Hayworth, Renzi, Cole, Pearce, Rahall, Kildee, Pallone, 

Christensen, Inslee, Napolitano, Tom Udall, Mark Udall, Carson, 

Bordallo and Baca 

STATEMENT OF HON. RICHARD W. POMBO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

The CHAIRMAN. The Committee on Resources will come to order. 

The Committee is meeting today to hear testimony on two bills 

dealing with health care for Native Americans: H.R. 151 and 

H.R. 2440, sponsored by Mr. Nethercutt and Mr. Young of Alaska, 

respectively. 

2

Under Rule 4(g) of the Committee Rules, any oral opening statements at hearings are limited to the Chairman and Ranking Minority Member. This will allow us to hear from our witnesses sooner and help members keep to their schedules. Therefore, if other 

members have statements, they can be included in the hearing 

record under unanimous consent. 

I would like to welcome all of the members and witnesses to this 

hearing on H.R. 151 and H.R. 2440. H.R. 151 is a bill to elevate 

the position of Director of Indian Health Service within the Department of Health and Human Services to Assistant Secretary of 

Indian Health. 

H.R. 2440 is the Indian Health Care Improvement Act Amendments. This is a huge bill which provides for health care delivery 

to over two million American Indians and Alaska Natives. 

H.R. 151 will provide a greater administrative focus on Native 

health issues by elevating the Director of the Indian Health Service 

within the Department of Health and Human Services to the Assistant Secretary of Indian Health. By providing a more visible internal role within the Department, the head of IHS will be a better 

advocate of Native health issues. 

While Secretary Tommy Thompson has certainly elevated the Director of IHS to a top level policy position, and he is to be applauded for this, previous Administrations have not placed such a 

premium on that position. I think that as we work on the larger 

Indian Health Care Improvement Act, we should look at whether 

elevating the Director to the Assistant Secretary level is good policy. 

The hearing on H.R. 2440 will focus on Title I, Indian Health 

Manpower. Title I of the bill strives to increase to the maximum 

extent feasible the number of American Indians and Alaska Natives entering the health professions. It also seeks to assure an 

adequate supply of health professionals to the Service, Indian 

tribes, tribal organizations, and urban Indian organizations involved in the delivery of health care to American Indians and Alaska Natives. 

By expanding Title I, tribes can get culturally proficient health 

care providers,. thereby increasing health care professionals. Further, the expansion of Title I will begin to address the challenges 

with recruitment and retention of direct health care providers for 

the most isolated, rural and remote American Indian and Alaska 

Native communities. 

I now recognize Mr. Rahall. 

[The prepared statement of Mr. Pombo follows:]

Statement of The Honorable Richard Pombo, a Representative in Congress 

from the State of California 

I would like to welcome all of the Members and witnesses to this hearing on 

H.R. 151 and H.R. 2440. H.R. 151 is a bill to elevate the position of Director of 

Indian Health Service within the Department of Health and Human Services to Assistant Secretary of Indian Health. 

H.R. 2440 is the Indian Health Care Improvement Act Amendments of 2003. This 

is a huge bill which provides for health care delivery to over 2 million American 

Indians and Alaska Natives. 

H.R. 151 will provide a greater administrative focus on Native health issues by 

elevating the Director of the Indian Health Service within the Department of Health 

and Human Services to the Assistant Secretary of Indian Health. By providing a 

3

more visible internal role within the Department, the head of the IHS will be a better advocate of Native health issues. 

While Secretary Tommy G. Thompson has certainly elevated the Director of IHS 

to a top-level policy position, and he is to be applauded for this, previous Administrations have not placed such a premium on that position, and I think that, as we 

work on the larger Indian Health Care Improvement Act, we should look at whether 

elevating the Director to the Assistant Secretary Level is good policy. 

The hearing on H.R. 2440 will focus on Title 1, Indian Health Manpower. Title 

I of the bill strives to increase to the maximum extent feasible, the number of American Indians and Alaska Natives entering the health professions. It also seeks to 

assure an adequate supply of health professionals at the Service, Indian tribes, tribal organizations, and urban Indian organizations involved in the delivery of health 

care to American Indians and Alaska Natives. 

By expanding Title I, tribes can get culturally proficient health care providers, 

thereby increasing health care professionals. Further, the expansion of Title I will 

begin to address the challenges with recruitment and retention of direct health care 

providers for the most isolated, rural and remote American Indian and Alaska Native communities. 

STATEMENT OF HON. NICK J. RAHALL, A REPRESENTATIVE IN 

CONGRESS FROM THE STATE OF WEST VIRGINIA 

Mr. RAHALL. Thank you, Mr. Chairman. 

Mr. Chairman, my home State of West Virginia has the distinction of being. although relatively small in population, still the distinction of singlehandedly causing the election of two United States 

Presidents. The first was John F. Kennedy who, by winning over 

largely Protestant West Virginia, dispelled the notion in certain 

quarters that he would be a Catholic President beholden to the 

Pope in Rome. 

The second, of course, was George W. Bush, because if West Virginia had voted the way it historically had done, Al Gore would be 

in the White House today, regardless of what happened in Florida. 

I raise this in reference to JFK because he was so moved by the 

poverty he saw in West Virginia during his campaign that when 

he became President he did something about it, by starting what 

became known as the Appalachian Regional Commission. A centerpiece of this initiative aimed at economic rejuvenation was ensuring that the region was equipped with adequate health care facilities to serve the public. Indeed, under the ARC, hospitals, treatment facilities and child care facilities were constructed as a means 

to help lift the people from poverty. 

We face the same task in Indian Country today. Yet, the Appalachian Regional Commission went from concept in 1963 to reality 

in 1965, in a shorter period of time than it has taken Congress to 

reauthorize the Indian Health Care Improvement Act. I find this 

situation to be intolerable. 

I understand that the issues involved here are complex, but the 

landmark National Steering Committee proposal was delivered to 

Congress in 1999. The law technically expired in 2001. A hearing 

record has been established and I am sure today’s hearing will be 

beneficial and I thank the witnesses for being with us. 

But the fact remains that people are suffering in Indian Country. 

Compared to all races in the United States, Native Americans suffer a death rate that is 533 percent higher from tuberculosis, 420 

percent higher from diabetes, 770 percent higher from alcoholism, 

and 71 percent higher from influenza and pneumonia. 

4

We must not stand idle any longer. We must move now to reauthorize the Indian Health Care Improvement Act so that we can 

better provide for the delivery of health services for American 

Indians and Alaska Natives throughout the Nation. 

I thank you, Mr. Chairman, for calling this hearing today, and 

thank you for your help on this issue as well. 

[The prepared statement of Mr. Rahall follows:]

Statement of The Honorable Nick J. Rahall II, a Representative in Congress 

from the State of West Virginia 

Mr. Chairman, West Virginia has the distinction of being the State which, although relatively small in population, singlehandedly caused the election of two U.S. 

Presidents. The first was John F. Kennedy, who, by winning over the largely Protestant West Virginia, dispelled the notion in certain quarters that he would be a 

Catholic President, beholden to the Pope in Rome. 

The second, of course, was George W. Bush, because, if West Virginia had voted 

the way it historically did, Al Gore would be in the White House today regardless 

of what happened in Florida. 

I raise this in reference to JFK, because he was so moved by the poverty he saw 

in West Virginia during his campaign that, when he became President, he did something about it by starting what became the Appalachian Regional Commission. 

A centerpiece of this initiative, aimed at economic rejuvenation, was insuring that 

the region was equipped with adequate health care facilities to serve the public. And 

indeed, under the ARC, hospitals, treatment centers and child care facilities were 

constructed as a means to help lift the people from poverty. 

We face the same task in Indian Country today. Yet, the Appalachian Regional 

Commission went from concept in 1963 to reality in 1965 in a shorter period of time 

than it is taking Congress to reauthorize the Indian Health Care Improvement Act. 

I find this situation to be intolerable. 

I understand the issues involved here are complex, but the landmark National 

Steering Committee Proposal was delivered to Congress in 1999. The law technically 

expired in 2001. A hearing record has been established. And I am sure that today’s 

hearing will be beneficial. 

But the fact remains that people are suffering in Indian Country. 

Compared to all races in the United States, Native Americans suffer a death rate 

that is 533% higher from tuberculosis, 420% higher from diabetes, 770% higher from 

alcoholism, and 71% higher from influenza and pneumonia. 

We must not stand idle any longer. We must move now to reauthorize the Indian 

Health Care Improvement Act so that we can better provide for the delivery of 

health services for American Indians and Alaska Natives throughout the Nation. 

Thank you. 

The CHAIRMAN. Thank you. 

I would now like to introduce our first witness, Congressman 

George Nethercutt, who represents the 5th District of the State of 

Washington and who is the lead sponsor on H.R. 151. 

Let me take this time to remind all of today’s witnesses that 

under our Committee Rule, oral statements are limited to 5 minutes. Your entire written testimony will appear in the record. 

Mr. KILDEE. Mr. Chairman. 

The CHAIRMAN. Mr. Kildee. 

Mr. KILDEE. I have another markup on my other committee. 

Could I submit comments for the record? I am a cosponsor of both 

these bills. 

The CHAIRMAN. Are they good comments? 

Mr. KILDEE. They’re great comments. 

[Laughter.] 

The CHAIRMAN. Without objection. 

Mr. KILDEE. Thank you, Mr. Chairman. 

[The prepared statement of Mr. Kildee follows:]

5

Statement of the Honorable Dale E. Kildee, a Representative in Congress 

from the State of Michigan 

Good morning. Mr. Chairman, I would like to thank you scheduling this hearing 

today. 

I would like to express my strong support for two very important bills, H.R. 2440, 

the reauthorization of the Indian Health Care Improvement Act, and H.R. 151, the 

bill to elevate the Director of Indian Health Service to Assistant Secretary status. 

I am proud to be an original cosponsor of both bills. 

The Indian Health Care Improvement Act, first enacted in 1976, is the keystone 

federal law that made vast improvements in the delivery of heath care provided to 

American Indian and Alaska Native people. 

Reauthorization of this Act will provide a more comprehensive approach to the delivery of medical care to Native people. 

This bill is based upon the recommendations made by the Indian Health Community including tribal leaders, tribal health directors, health care experts, and Native 

patients themselves. 

Its primary objective is to improve access to quality medical care for the Native 

American population. 

Previous amendments to the Indian Health Care Improvement Act reflect advancements in health care delivery, respond to the desire of tribes for greater responsibility over programs, and target high incidence of certain diseases that have 

plagued the Native American segment of the American population. 

The proposed changes to the bill will build upon the basic framework of the 

Indian Health Care Improvement Act. 

Mr. Chairman, by elevating the Director of Indian Health Service to Assistant 

Secretary status, Congress will be sending a clear message to Indian Country that 

their Indian health needs are a priority for us. 

The disparity of health care delivery to American Indians and Alaska Native communities is disproportionately less than the general population in the United States. 

Native Americans suffer from diabetes, alcoholism, tuberculosis, and heart disease 

at far higher rates than non-Indians. 

Having an Assistant Secretary that directly reports to the Secretary of DHHS is 

a major step toward addressing the health needs in Indian communities whose 

health needs exceed $15 billion. 

I look forward to hearing from the witnesses. Thank you. 

Mr. CARSON. Mr. Chairman, could I also ask your indulgence to 

do the same? 

The CHAIRMAN. Without objection, Mr. Carson will also introduce 

a statement into the record. 

[The prepared statement of Mr. Carson follows:]

Statement of The Honorable Brad Carson, a Representative in Congress 

from the State of Oklahoma 

Chairman Pombo, Ranking Member Rahall, I would like to thank you both for 

conducting a hearing on these two critically important pieces of legislation. I am a 

cosponsor and strong supporter of both H.R. 151, legislation to elevate the Indian 

Health Service (IHS) Director to the Assistant Secretary for Indian Health, and 

H.R. 2440, legislation to reauthorize the Indian Health Care Improvement Act. 

Every year, raising the standard of health care for every American is a high priority for Congress. However, this continuing debate often ignores the standard of 

health care in Indian country. 

To illustrate my point, I refer to a report published in July 2003, by the United 

States Commission on Civil Rights, titled, ‘‘Quiet Crisis: Federal Funding and 

Unmet Needs in Indian Country.’’ This report states: 

‘‘Native Americans receive less funding per capita than any other group for 

which the federal government has health care responsibilities, including 

Medicaid/Medicare recipients, veterans, and prisoners. The legal and moral 

obligation to provide health care to Native Americans has not been met, 

and unless IHS receives an exponential increase in funding, health conditions are not likely to improve and will likely worsen.’’

Further, the report states that the national per capita health expenditure for the 

average American will be $5,775 in 2003. Compare this to the $1,914 that IHS is 

projected to spend per capita in 2003. To put it simply, 3 times more is spent on 

6

the health care of average American citizens than on the Indian people of this nation. 

In looking at these statistics, I am puzzled as to why the principle health care 

provider and advocate for Indian Health Care is not an Assistant Secretary position. 

While the goal of IHS is to raise the health status of American Indians and Alaska 

Natives to the highest level possible, the current administrative structure limits the 

IHS Director’s authority to set and implement health policy for American Indians. 

By elevating the IHS Director to an Assistant Secretary position, we will greatly 

strengthen the voice of Indian Country as we all work together to raise the standard 

of health care in this country and to address urgent unmet health care needs. 

I also want to say a few words of support regarding H.R. 2440. The most recent 

reauthorization of the Indian Health Care Improvement Act was in 1992. Since that 

time the Indian population has grown and the disparity between the health status 

of Indian people as compared to other Americans has grown. To address these 

changing circumstances more fully and effectively, a reauthorization is desperately 

needed to reflect these changes since the last reauthorization 11 years ago. In recent 

years, the Indian health care community, namely the National Steering Committee, 

has been working hard to draft reauthorization legislation, and H.R. 2440 is the 

product of their diligence. It is time for Congress to do its part and move this legislation forward for eventual enactment into law. 

The CHAIRMAN. Mr. Nethercutt. Welcome to the Committee. It’s 

nice to have you here today. You know the rules and you can begin. 

STATEMENT OF HON. GEORGE R. NETHERCUTT, JR., A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF 

WASHINGTON 

Mr. NETHERCUTT. I will, Mr. Chairman. I thank you very much, 

to you and the Ranking Minority Member and all the members of 

the Committee for holding this hearing on H.R. 151. I am especially thankful to my friend, Congressman Hayworth, for cosponsoring, and others for giving this bill so much consideration, and 

other cosponsors who are sitting on this panel. 

We have submitted a statement for the record and I would ask 

that it be submitted in its entirety, and I will just summarize my 

remarks this morning to emphasize the importance that I think 

this bill holds for American Indian and Native American communities across this country. It would elevate the position of the Director of the Indian Health Service within the Department of HHS, 

Health and Human Services, to Assistant Secretary for Indian 

Health. 

I think it’s an appropriate thing to do, given our national commitment to our Native American and Alaska Native populations 

across this country, and also in recognition of the fact that our 

American Indian and Alaska Native population suffer disproportionately certain kinds of diseases, chronic conditions such as diabetes. I know many of you are part of the Diabetes Caucus in the 

House, the largest caucus in the House that focuses on the chronic 

disease of diabetes. 

Its impact on minority populations, and especially our American 

Indian and Alaska Native populations, is profound. Its impact is 

disproportionate to the rest of the population. 

In addition, I have visited in my own State, and in my own district, a number of Indian Health Service facilities, Indian health 

clinics and other health delivery services that exist on our tribal 

lands today. They are struggling, these various tribal organizations 

and entities. They are in need of additional attention on the very 

7

critical issue of human health as it relates to our Native American 

and Alaska Native populations. 

So this bill is a logical second or third step in our focus on what 

is necessary to help meet the health care needs of our Native 

American and Alaska Native populations; that is, to give greater 

priority within the Department that implements these programs by 

elevation of this Director of Indian Health Services to an Assistant 

Secretary for Indian Health. By doing so, this Assistant Secretary 

will sit at the table with the Secretary and discuss, on a day to 

day, week to week, annual basis the health care needs of the populations that the Assistant Secretary would serve, and also advocate 

very strongly for additional funding, additional programs, or additional assistance to our Native American populations, who struggle 

mightily in the area of chronic disease. 

So I would just say to the Committee, and to you, Mr. Chairman, 

and all the others, this is a good bill. It’s a fair bill. It is one that 

I think addresses the critical need of Indian health care in this 

United States, and I think it certainly pays adequate respect to our 

Native American populations and their special needs in this country, especially as it relates to diabetes and other health care conditions. 

So I would urge you to favorably consider this legislation, report 

it out expeditiously, and hopefully we could pass it in the House 

and Senate, and then do justice to those who are in the greatest 

need in our country, who are part of this great heritage of Native 

Americans and Alaska Natives. I think, in passing this legislation, 

we will pay proper respect to them and their particular health care 

needs, as well as the tradition of providing health care assistance 

to our Native American populations since this country was formed. 

So I would urge your favorable consideration. 

I would be happy to answer any questions, and I thank you so 

much for taking the time today to hold this hearing and allow this 

testimony, not just from me but from the other very distinguished 

panels that will follow, who will testify in support of this measure. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Nethercutt follows:]

Statement of The Honorable George R. Nethercutt, Jr., a Representative in 

Congress from the State of Washington 

Thank you for the opportunity to appear before you today in support of H.R. 151. 

As you know, the Indian Health Service (IHS) is the lead agency in providing health 

care to the more than 550 Indian tribes in the United States. Each year the IHS 

serves 1.3 million American Indians and Alaska Natives. The services the IHS oversees range from facility construction to pediatrics. 

As Co-Chair of the Congressional Diabetes Caucus, I have worked closely with the 

IHS. The statistics for Native Americans with diabetes are staggering. Over 15 percent of the Native Americans receiving care from IHS have diabetes. Prevalence of 

type 2 diabetes among Native Americans over 19 years of age is 12.2%. This compares to a 7.3% prevalence rate for the U.S. population as a whole. One tribe in 

Arizona has the highest rate of diabetes in the world. About 50% of these adults 

between the ages of 30 and 64 have diabetes. Diabetes has reached epidemic proportions among Native Americans. Complications from diabetes are major causes of 

death and health problems in most Native American populations. The serious complications of diabetes are increasing in frequency among Native Americans. Of 

major concern are increasing rates of kidney failure, amputations and blindness. I 

believe that H.R. 151 will afford IHS a stronger advocacy function within HHS, and 

allow for increased representation during the budget process. 

8

Currently, the ability of the IHS to affect budgetary policy is limited, in part, by 

the Director’s inability to directly participate in budget negotiations. As you may 

know, the IHS director position currently falls under the authority of the Public 

Health Service. The IHS employs approximately 15,000 employees and consists of 

594 direct health care delivery facilities, yet IHS does not have the direction of an 

Assistant Secretary. 

Each year the IHS provides health care services to 559 Indian tribes in 35 states. 

The purchasing power of the IHS budget is steadily declining and efforts to address 

Indian health care needs have not greatly helped. The disparity between Indian and 

non-Indian communities in Federal health care expenditures is growing. 

Mr. Chairman, the Federal Government is not meeting the needs of Indian people. 

The lack of broad-based advocacy for Native American health needs is partially to 

blame and I believe this legislation is a step in the right direction. If H.R. 151 is 

enacted into law, it would be much easier for the director of IHS to ensure that 

HHS funding is available to meet the health needs of Indian communities. I hope 

that this bill will receive favorable consideration by your Committee and the entire 

Congress. 

Mr. GIBBONS [presiding]. Thank you very much, Mr. Nethercutt. 

Are there any questions for Mr. Nethercutt? Mr. Pallone. 

Mr. PALLONE. Thank you, Mr. Chairman. 

I don’t know if this directly relates, but I do support your legislation. I think we should try to move the legislation as quickly as 

possible. 

Two things. One, you know that there is a chronic shortfall in 

funding for the Indian Health Service, which all of us bemoan and 

in which I think a lot of us would like to see a significant increase. 

So I have two questions. 

One, do you think this would be beneficial in the sense that 

maybe this person at a higher level is better able to advocate for 

more funding? That’s number one. And the second thing is—and I 

don’t know the details, but there is this proposal by the Bush Administration that would transfer a lot of the people who are in the 

Indian Health Service over to the Secretary of Health and Human 

Services office, which again people in Indian country seem to think 

is a bad idea because it will dilute their—In other words, if they 

are directly under the Secretary rather than a part of the Indian 

Health Service, there may be a negative impact on the Indian 

Health Service. 

I was wondering how that would relate to this legislation as well, 

how you feel about that and whether or not elevating this position 

at the same time the Administration is trying to transfer these people to the Secretary’s office, how you feel about the interaction 

there. Those are the two questions. 

Mr. NETHERCUTT. Well, Congressman Pallone, I thank you for 

the questions. 

I serve on the Appropriations Committee, the Interior Subcommittee, which does the funding for the Indian Health Service. 

We are trying our best to increase those Federal funds that go for 

Indian health, so we will advocate for that very strongly. 

I think that having this Assistant Secretary position in place will 

allow for that greater advocacy. I think the Director comes to our 

Subcommittee and testifies in favor of additional resources. But I 

think internally, in the Department of Health and Human Services, 

there will be a greater opportunity for advocacy for additional moneys that will also flow into other subcommittees, so I think the net 

9

effect will be positive on funding and also on advocacy opportunities. 

With respect to your second question about the movement of staff 

positions, I can testify first hand that Secretary Thompson is such 

a strong advocate for the subject of diabetes and diabetes funding 

and assistance, and he was a strong advocate for the extra $750 

million over 5 years that goes to type II Native American disease 

research. So it may be that the net impact will be positive rather 

than negative, if that, in fact, happens. I don’t have a good sense 

of whether it will or it won’t. But I know Secretary Thompson is 

such a strong advocate for those in Indian country who suffer from 

diabetes and otherwise and will be a strong voice within the Department and perhaps this will bolster this argument that we need 

to enhance the amount of money that we spend and the time and 

attention we spend on Indian health. So that’s my hope. 

Mr. PALLONE. I guess the problem that I have—and again, I 

don’t have all the details in front of me—is that on the one hand 

I agree with what you just said, that the elevation of this position 

certainly helps in terms of having a greater advocate and somebody 

who can maybe get more funds. But if you transfer a lot of the positions over to the Secretary’s office, it seems to me that it dilutes 

the fact that you want to put all these people under one director, 

in this case somebody who is being elevated and becoming more 

important, and it sort of undercuts your efforts by having these 

people transferred to the Secretary’s office. 

You know, it is hard to quantify that, but that would be my impression. But you don’t seem to feel that that’s true? 

Mr. NETHERCUTT. I guess my sense of it would be this. If we pass 

H.R. 151 and report it out and it gets favorable consideration, 

maybe then we are in a position to go to the Secretary or to the 

Administration and say we have now elevated the Director to Assistant Secretary and are you sure you want to make these transfers, is this something that’s valid to do. So maybe this action by 

this Committee and the House and the Senate might then lead to 

the kind of result which I think we all want, and that is more attention to Indian health and more advocacy for it and more adequate staffing to make sure the job gets done. 

Mr. PALLONE. Thank you. I appreciate that, and I support the 

bill. 

Thank you, Mr. Chairman. 

Mr. GIBBONS. Thank you, Mr. Pallone. 

Anybody else? Mr. Rahall. 

Mr. RAHALL. Thank you, Mr. Chairman. 

I want to thank the gentleman from Washington for not only his 

recognition of the problem but for his leadership, especially from 

his position on the Appropriations Committee. 

My question relates to the position of the Administration, the 

testimony of which is about to be presented to us. I understand 

they are going to testify that we do not need to elevate the Director 

of Indian Health Services to that of Assistant Secretary because 

they have elevated him ‘‘in house’’ by giving him direct access to 

the Secretary. My thinking is that this does not necessarily give 

him better budget authority access and it doesn’t provide the next 

Secretary with the same direct access. 

10

So my question is, how do you feel about the Administration’s position on this issue? 

Mr. NETHERCUTT. Well, I would just say, Mr. Rahall, that I support H.R. 151. I think it’s the right result and I think it’s the right 

action to take. I think you make a good point relative to the next 

Secretary that might be in the position. 

I know this Secretary to be a very honorable man and very dedicated to the issue of Indian health and also diabetes, so there is 

open access. I think that’s a good thing. 

But institutionally, I prefer to see H.R. 151 passed and enacted 

into law, and then we have assurance relatively in perpetuity that 

there would be that access and there would be that advocacy at the 

table for budget items and other things that might come to affect 

Indian health. So I respect the Administration, as you know, but 

I also have high regard for our bill and I think it’s the right thing 

to do. 

Mr. RAHALL. Thank you. 

Thank you, Mr. Chairman. 

Mr. GIBBONS. Thank you, Mr. Rahall. 

Mrs. Christensen. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. I want to thank 

you for holding this hearing and I want to thank our colleague for 

introducing the bill. 

I wanted to say that the health task forces of the minority caucuses have been working together to create and introduce a bill 

which was to have actually been introduced today but is delayed, 

and within that bill we include your bill, the Indian Health Care 

Improvement Act, so we are glad to see it here before us today and 

offer our support. 

We know how health care disparities have affected our Native 

American population, and we intend to continue to include this bill 

within the more comprehensive bill that addresses the health care 

disparities for all people of color and we also hope that our colleagues will support the larger bill as well as we seek to bring equity and accountability into health care for everyone. 

Mr. NETHERCUTT. Thank you so much. 

I would just add, too, that our minority populations in this country suffer disproportionately certain kinds of chronic health care 

conditions, diabetes being a very important one. Our Hispanic populations, our black populations, our Native American populations, 

all of them have a disproportionately higher incidence of the disease. 

So my goal, as Co-Chairman with Diana Degette and others in 

the House, is to really focus on chronic disease conditions. As we 

put more money in, as we advocate harder and stronger, I think 

we will get a better handle for generations to come on all minority 

populations, and that’s the right thing to do for our country. 

Mrs. CHRISTENSEN. If I could just add, that bill is also included 

in our comprehensive bill. 

Mr. NETHERCUTT. Thank you so much. 

Mr. GIBBONS. Mrs. Napolitano. 

Mrs. NAPOLITANO. Thank you, Mr. Chairman. 

I am one of the cosponsors, so you know I support the bill. 

Mr. NETHERCUTT. Good. 

11

Mrs. NAPOLITANO. My question, again dovetailing on some of the 

comments my colleagues have made, is that the IHS employs about 

15,000 employees, almost a quarter of all of HHS personnel. Is this 

adequate? Is this something where personnel is not focusing on the 

issues that affect the Indian Nation? Why is there not enough support then if there is this number of employees? 

Mr. NETHERCUTT. Well, I think the critical issues—there are a 

lot of issues that affect Native Americans, for example, and in the 

Indian Health Service it’s a monumental task out there among I 

think 559 tribes across this country. I think the goal is to make 

sure those 15,000 employees, or however many there are, dispersed 

through the Government that focus on Indian health are going to 

do good work and have effective solutions to the problems that face 

all of our tribal organizations as well as those who are affected by 

chronic disease. 

Maybe I’m not answering your question as precisely as you would 

like, but as I understand it, I think there is more advocacy to be 

gained and there is also more effective advocacy to be gained 

within Government agencies today. I’m not so sure we should look 

at it just from the number of employees, but we have to look at 

what is the advocacy level, what are the issues that they’re stressing prominently, and what are the results. So I think our goal with 

this $750 million over 5 years of mandatory funding, as well as additional money for diabetes, for example, we have to make sure 

that money is well spent. 

So to the extent those employees can help make sure that money 

is well spent and that we have good plans in place for Indian 

health, we’re all going to be better off and so are those affected by 

it are better off. 

Mrs. NAPOLITANO. I understand that. Coming from a State legislature, I have found that sometimes some of those positions are 

used for other purposes. 

Mr. NETHERCUTT. Sure. 

Mrs. NAPOLITANO. Certainly there needs to be more of a focus. 

I know these issues have been identified before, and at that joint 

hearing we held with the Senate, all those issues were brought out. 

I would hope that we focus on what we have found, what the 

Indian Nation representatives have spoken to, that we do not let 

those issues go by the wayside. You talked just about diabetes. 

There are other issues that were brought up, including, of course, 

alcoholism, asthma, a lot of the issues that the young children are 

beginning to show. We should not let those sit by the wayside while 

we’re arguing over whether or not we need to get the programs 

going. 

Mr. NETHERCUTT. I understand. I think maybe the elevation of 

this Indian Health Service Director to Assistant Secretary would 

give greater authority and greater opportunity to collect the resources of Government for the right purposes that you’re speaking 

of. 

Mrs. NAPOLITANO. But it’s not creating another bureaucracy, I 

hope. 

Mr. NETHERCUTT. I don’t think so. I think we’re really just giving 

greater ability and greater authority of that particular director to 

manage in an effective way within the agency and bureaucracy of 

12

government. I say that respectfully. I think this may be a better 

way to have efficiency, rather than creating an additional bureaucracy. I think it’s just the opposite. I think it will be greater efficiency and greater opportunity, greater authority on the part of 

that person to lead the charge for Indian health improvement. 

Mrs. NAPOLITANO. Thank you. 

Mr. GIBBONS. Thank you very much. 

Are there other members who have questions at this point in 

time? If not, Mr. Nethercutt, we thank you for your presentation 

and we will excuse you for now and call up our second panel. 

Mr. NETHERCUTT. Thank you, Mr. Chairman. 

Mr. GIBBONS. I would now like to call up the second panel on 

this issue, Mr. Michel Lincoln, Deputy Director, Indian Health 

Service. 

Mr. Lincoln, we have a policy in this Committee of swearing in 

our witnesses, so if you will rise and take the oath, we would appreciate it. 

[Witness sworn.] 

Let the record reflect that the witness answered in the affirmative. Mr. Lincoln, welcome to the Committee. The floor is yours. We 

look forward to your testimony. 

STATEMENT OF MICHEL LINCOLN, DEPUTY DIRECTOR,

INDIAN HEALTH SERVICE 

Mr. LINCOLN. Thank you, Mr. Chairman, and members of the 

Committee. I am privileged to be here today in front of the 

Committee to testify on behalf of the Indian Health Care Improvement Act and Title I of the Indian Health Care Improvement Act. 

It is my pleasure to say that, indeed, the Department and the 

Secretary support the reauthorization of the Indian Health Care 

Improvement Act. 

I know it is difficult to talk about Title I in the absence of talking 

about other issues that are prominent throughout Indian country, 

and many of those have just been discussed between the dialog 

with Congressman Nethercutt and members of this Committee. 

I should also add another qualification, Mr. Chairman—and I 

will be giving a brief oral statement—in that I have the distinct 

privilege, I guess, to have lived as long as I have and had the privilege in 1976 to be around and working in health when the original 

Indian Health Care Improvement Act was passed by this Congress. 

I had the privilege, indeed, in follow up to the passage of that Act, 

to work in help writing the specifications that resulted in the regulations implementing Title I of this Act, primarily the Indian 

health professions piece, the scholarships, and the loan repayment 

piece. So I have a little bit of history relative to the impact. 

I would like to say, though, as this Committee knows, the Indian 

Health Service is the primary provider for health care services on 

behalf of the Federal Government for approximately 1.6 million 

American Indians and Alaska Natives throughout our great Nation. The mission of the agency is indeed to raise the physical, 

mental, social and spiritual health of American Indians and Alaska 

Natives to the highest level, in partnership with the population we 

serve. 

13

This particular piece of legislation, combined with the Snyder 

Act, which was passed in 1921, really serves as the basis, the foundation, if you will, for Indian health legislation in this Nation—indeed, the policy that is articulated within those two documents. 

They are both important documents, especially when taken together, as you look at improvements made over the years. 

I would like to say that this bill that is before you has been the 

result of extensive work between tribal governments, among tribal 

governments, among Indian health professionals, among the Indian 

Health Service certainly, and with our colleagues throughout the 

Department of Health and Human Services. It is a product of genuine thinking, genuine collaboration, and genuine disagreement in 

many instances. We look forward to working with the Committee 

as you all consider this bill and move this piece of legislation forward. 

I would like to reiterate a couple of statistics that were given for 

the health status throughout Indian country. I don’t believe it is 

possible to talk about health professions scholarship or health facilities or health services or any other piece of the Indian Health 

Service programs, or health programs in general, without acknowledging some of the basic statistics. 

One of those statistics, indeed, is that alcoholism mortality is 770 

percent, the data mentioned before, seven times the U.S. all-races 

deaths due to alcoholism. Diabetes is four times, accidents are 

three times higher, suicides two times higher, and homicides two 

times higher. 

I think what is important about these statistics, and maybe the 

tragedy of what is going on, is that, for the most part, these chronic 

diseases that Congressman Nethercutt spoke of, certainly including 

diabetes, but the others that I have mentioned, are all preventable. 

It seems to me that certainly our new Director, Dr. Charles Grim, 

is revitalizing and reemphasizing preventive health programs 

throughout this Nation. There must be a preventive piece in here, 

not only from a health care standpoint but from a conscience standpoint. It just seems like it’s the right thing to do. 

I do want to describe these health programs also within the context of great demands and great needs for community development, 

for economic development, for education opportunities, for all the 

individuals within the community settings where our families, children and parents live. I believe it is especially important that we 

not forget about the community view of what this piece of legislation brings in front of us. 

I would certainly mention a couple of additional diseases that 

need to be reemphasized. Congressman Nethercutt, more than I 

could, has been at the forefront of diabetes, preventing diabetes 

and treating diabetes. Through the legislation that Congress 

passed, we will certainly see improvements in diabetes mortality, 

and hopefully we will see over time a reduction in the incidence of 

diabetes. 

The same needs to be said relative to cardiovascular disease, 

though. It is indeed the leading cause of death of Indian people 

throughout this country. It is increasing at a time when cardiovascular disease in most other populations in this Nation is 

decreasing. So there is the opposite trend, the inverse that is occurVerDate 0ct 09 2002 13:22 Mar 26, 2004 Jkt 088533 PO 00000 Frm 00017 Fmt 6633 Sfmt 6602 J:\DOCS\89608.TXT HRESOUR1 PsN: KATHY
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ring relative to cardiovascular disease in Native American populations. 

I would like to move very quickly into a summary and to let you 

know about very specific information that is not part of my testimony on the health professions piece. 

These programs of scholarships and loan repayment have made 

an impact in Indian country. In 1981, there were only 697 Indian 

people who were health providers through the Indian Health Service system. In 2002, there are now in excess of 2,500 American 

Indian and Native Alaska people who are health providers within 

this health delivery system. 

Thirty-seven percent of all of our health providers are now 

Indian people. In my opinion, that would not have happened in the 

absence of a focus, a concentrated effort to increase the number of 

Indian people pursuing the health professions and, quite frankly, 

providing the opportunities through loan repayment and other 

kinds of incentives and encouraging those individuals to return to 

their communities to provide services to their own people. 

Mr. Chairman, if I may give you one more set of statistics, I will 

then end my testimony. An example of the kinds of vacancy rates 

that are currently within Indian country, indeed, in many ways 

might mirror the rest of the population for a few of the professions, 

but in general are worse in Indian country. Right now, today, our 

vacancy rate for nurses, for professional nurses, is 14 percent. 

Today, the vacancy rate for physicians is 10 percent. The vacancy 

rate for dentists is at 22 percent, and for some specialties within 

these professions, like nurse anesthetists, the vacancy rates are 33 

percent. There is a need for Title I to assist these health programs, 

both tribal, Federal and urban programs, in filling these much 

needed health providers. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Lincoln follows:]

Statement of Michel Lincoln, Deputy Director, Indian Health Service 

Mr. Chairmen and Members of the Committees: 

Good morning, I am Michel Lincoln, Deputy Director of the Indian Health Service 

(IHS). We are pleased to have this opportunity to testify on behalf of Secretary 

Thompson on H.R. 2440, the Indian Health Care Improvement Act Amendments of 

2003, and H.R. 151, the bill to elevate the position of Director of the Indian Health 

Service within the Department of Health and Human Services to Assistant Secretary for Indian Health. At the Committee’s request, I will discuss Title I—Indian 

Health, Human Resources, and Development of H.R. 2440; and H.R. 151, the bill 

to elevate the IHS Director. 

The IHS has the responsibility for the delivery of health services to more than 

1.6 million Federally recognized American Indians and Alaska Natives (AI/ANs) 

through a system of IHS, tribal, and urban (I/T/U) operated facilities and programs 

based on treaties, judicial determinations, and Acts of Congress. The mission of the 

agency is to raise the physical, mental, social and spiritual health of AI/ANs to the 

highest level, in partnership with the population we serve. The agency goal is to 

assure that comprehensive, culturally acceptable personal and public health services 

are available and accessible to the service population. Our foundation is to promote 

healthy American Indian and Alaska Native people, communities and cultures and 

to honor and protect the inherent sovereign rights of Tribes. 

Two major pieces of legislation are at the core of the Federal government’s responsibility for meeting the health needs of American Indians/Alaska Natives (AI/ANs): 

The Snyder Act of 1921, P.L.67-85, and the Indian Health Care Improvement Act 

(IHCIA), P.L.94-437. The Snyder Act authorized regular appropriations for ‘‘the relief of distress and conservation of health’’ of American Indians/Alaska Natives. The 

IHCIA was enacted ‘‘to implement the Federal responsibility for the care and eduVerDate 0ct 09 2002 13:22 Mar 26, 2004 Jkt 088533 PO 00000 Frm 00018 Fmt 6633 Sfmt 6621 J:\DOCS\89608.TXT HRESOUR1 PsN: KATHY
15

cation of the Indian people by improving the services and facilities of Federal Indian 

health programs and encouraging maximum participation of Indians in such programs.’’ Like the Snyder Act, the IHCIA provided the authority for the programs 

of the Federal government that deliver health services to Indian people, but the 

IHCIA also provided additional guidance in several areas. The IHCIA contained specific language that addressed the recruitment and retention of a number of health 

professionals serving Indian communities. 

I am here today to discuss reauthorization of the IHCIA and tribal recommendations for change to the existing IHCIA in the context of the many changes that have 

occurred in our country’s health care environment since the law was first enacted 

in 1976. H.R. 2440 reflects the product of an extensive tribal consultation process 

that took two full years and resulted in a tribally drafted reauthorization bill. IHS 

and other HHS staff provided technical assistance and support to the Indian Tribes 

and urban Indian health programs through this lengthy consultation. However, we 

recognize that our programs overlap and have implications for other Department 

agencies and their programs, and we are continuing to work with them to develop 

a comprehensive Administration position on this legislation. 

Health Disparities 

While the mortality rates of Indian people have improved dramatically over the 

past ten years, Indian people continue to experience health disparities and death 

rates that are significantly higher than the rest of the U.S. general population: 

• Alcoholism—770% higher 

• Diabetes—420% higher 

• Accidents—280% higher 

• Suicide—190% higher 

• Homicide—210% higher 

Those statistics are startling, yet they are so often repeated that some view them 

as insurmountable facts. But every one of them is influenced by behavior choices 

and lifestyle. Making significant reductions in health disparity rates, and even 

eliminating them, can be achieved by implementing best practices, using traditional 

community values, and building the local capacity to address these health issues 

and promote healthy choices. 

A primary area of focus that I have identified based on these statistics is a renewed emphasis on health promotion and disease prevention. I believe this will be 

our strongest front in our ongoing battle to eliminate health disparities plaguing our 

people for far too long. Although we have long been an organization that emphasizes 

prevention, I am calling on the Agency to undertake a major revitalization of its 

public health efforts in health promotion and disease prevention. Both field and tribal participation in the initial stages of planning and implementation are critical. 

Fortunately, the incidence and prevalence of many infectious diseases, once the 

leading cause of death and disability among American Indians and Alaska Natives, 

have dramatically decreased due to increased medical care and public health efforts 

that included massive vaccination and sanitation facilities construction programs. 

Unfortunately, as the population lives longer and adopts more of a western diet and 

sedentary lifestyle, chronic diseases emerge as the dominant factors in the health 

and longevity of the Indian population with the increasing rates of cardiovascular 

disease, Hepatitis C virus, and diabetes. 

Cardiovascular disease is now the leading cause of mortality among Indian people, 

with a rising rate that is significantly higher than that of the U.S. general population. This is a health disparity rate that the President, the Secretary of Health 

and Human Services, and the IHS are committed to eliminating. The IHS is working with other HHS programs, including the Centers for Disease Control and Prevention and the National Institutes of Health’s National Heart Lung and Blood Institute, to develop a Native American Cardiovascular Disease Prevention Program. 

Also contributing to the effort is the IHS Diabetes Program, the IHS Disease Prevention Task Force, and the American Heart Association. The primary focus is on 

the development of more effective prevention programs for AI/AN communities. The 

IHS has also begun several programs to encourage employees and our tribal and 

urban Indian health program partners to lose weight and exercise, such as ‘‘Walk 

the Talk’’ and ‘‘Take Charge Challenge’’ programs. 

Diabetes mortality rates have been increasing at almost epidemic proportions. 

American Indians and Alaska Natives have the highest prevalence of type 2 diabetes in the world. The incidence of type 2 diabetes is rising faster among American 

Indians and Alaska Native children and young adults than in any other ethnic population, and is 2.6 times the national average. As diabetes develops at younger ages, 

so do related complications, such as blindness, amputations, and end stage renal 

disease. Today, however, I want to report to you that we may be seeing a change 

16

in this pattern. In CY 2000 we have observed for the first time ever a decline in 

mortality. I must note that this is preliminary mortality data that needs to be further examined. 

What is most distressing however about these statistics is that type 2 diabetes 

is largely preventable. Lifestyle changes, such as changes in diet, exercise patterns, 

and weight can significantly reduce the chances of developing type 2 diabetes. Focusing on prevention not only reduces the disease burden for a suffering population, 

but also lessens and sometimes eliminates the need for costly treatment options. 

The cost-effectiveness of a preventative approach to diabetes management is an important consideration, since the cost of caring for diabetes patients is staggering. 

Managed care estimates for treating diabetics range from $5,000-$9,000 per year. 

Since the Indian health system currently cares for approximately 100,000 people 

with diagnosed diabetes, this comes out to a conservative estimate of $500 million 

just to treat this one condition. 

Another area of concern is in behavioral health, specifically the identification and 

treatment of depression and strategies for prevention of depression. A recent study 

from Washington University in St. Louis has revealed that untreated depression 

doubles the risk for chronic diseases like diabetes and cardiovascular disease, not 

to mention the risks for alcoholism, suicide and other violent events. This study also 

showed that of those individuals with chronic disease, unrecognized and untreated 

depression doubles the risk for complications of the chronic disease (e.g., amputations and renal disease in diabetics). We must find the best practices that will allow 

us to prevent depression primarily, or at the least recognize and treat it early if we 

are to reduce the disparities that affect Indian communities. 

A well-trained, caring staff, supported by sufficient funding, is the best means of 

successfully addressing these disparities. Programs authorized in Title I help us to 

obtain these people. Even better, three programs help us to ‘‘grow our own,’’ in that 

they support the development of Indian health professionals. 

The most influential of these programs are the scholarship program, authorized 

in Sections 103 and 104, and the loan repayment program, authorized in Section 

110. Over the years, the scholarship program has helped over 7,000 Indian students 

attend pre-professional and professional school. Its influence can readily be seen in 

the fact that since 1981, the proportion of IHS health professional staff that is 

Indian has increased by 131%. 

The loan repayment program has served both to attract and retain health professionals. Since its inception in 1988, more than 3,000 health professionals have participated. Many have stayed well beyond the time it took to repay their loans, having found that the IHS practice is what they are seeking. 

National shortages in nursing, dentistry, pharmacy and other health professions 

are having an impact on Indian health programs. We continue our efforts to attract 

the best. These programs, and others authorized in Title I, help in this effort. 

H.R. 151—Elevation of the IHS Director to Assistant Secretary for Indian Health 

H.R. 151 proposes to establish within the Department of Health and Human 

Services an Office of the Assistant Secretary for Indian Health. The IHS is the principal point of contact on behalf of the Department on health matters related to 

Tribes. It exists because of the solemn promises the Federal government has made 

to Indian people. On matters of health care, the head of the Indian Health Service 

acts principally as the administrator of the vast Indian Health Service system, as 

well as an advocate on behalf of the Indian Health needs of the nation’s more than 

550 federally recognized Indian Tribes. 

Currently, the Director of the IHS enjoys direct access to the Secretary in the Department on all health services issues that have an impact on Tribes and Tribal organizations. In addition, the Director serves as Vice Chair of the Secretary’s 

Intradepartmental Council for Native American Affairs. The Council serves as an 

advisory body to the Secretary and has the responsibility to assure that Native 

American policy is implemented across all Divisions in the Department, including 

human services programs. The Council also provides the Secretary with policy guidance and budget formulation recommendations that span all Divisions of HHS. A 

profound impact of this Council on the IHS is the revised premise within HHS that 

all agencies bear responsibility for the government’s obligation to the Native people 

of this country. 

It is our view that the Director as the Vice Chair of the Intradepartmental Council for Native American Affairs currently enjoys an elevated status in the Department. He facilitates advocacy, promotes consultation, reports directly to the Secretary, collaborates directly with the Assistant Secretary of Health, advises the 

heads of all the Department’s divisions and coordinates activities of the Department 

concerning matters related to Native American health and human services issues. 

17

This authority is provided in the Native American Programs Act of 1974. Consistent 

with the statute, Secretary Thompson has taken steps to assure that this Council 

receives the highest levels of attention within the Department. 

Moreover, the Secretary and Deputy Secretary have traveled widely to Indian 

Country with their senior staff. These trips have raised the awareness of tribal 

issues and have contributed greatly to our capacity to speak with one voice, as One 

Department, on behalf of tribes. Secretary Thompson and Deputy Secretary Allen 

are daily committed to working with Tribal leaders on Indian health concerns. 

The Director, then, currently is assured the same access to the highest levels as 

other agencies in the Department and it is not necessary to elevate the IHS Director 

to the level of Assistant Secretary over other agencies serving American Indians/

Alaska Natives (AI/AN). 

Summary 

In summary, preventing disease and injury is a worthwhile financial and resource 

investment that will result in long-term savings by reducing the need for providing 

acute care and expensive treatment processes. It also yields the even more important humanitarian benefit of reducing pain and suffering, and prolonging life. This 

is the path we must follow if we are to reduce and eliminate the disparities in 

health that so clearly affect AI/AN people. 

As we continue our thorough review of this far-reaching, complex legislation on 

reauthorization, we may have further comments on Title I. However, we wish to reiterate our strong commitment to reauthorization and improvement of the Indian 

health care programs. We will be happy to work with the Committees, the National 

Tribal Steering Committee, and other representatives of the American Indian and 

Alaska Native communities to develop a bill fully acceptable to all stakeholders in 

these important programs. 

Mr. Chairman, this concludes my statement. Thank you for this opportunity to 

discuss the reauthorization of the Indian Health Care Improvement Act and other 

issues. We will be happy to answer any questions that you may have. 

Mr. GIBBONS. Thank you very much, Mr. Lincoln. 

As we continue our discussion on H.R. 2440, I had a question for 

you with regard to Title I. Does Title I authorize program funding 

to provide for training in management health programs, like information technology and business administration? 

Mr. LINCOLN. At the current time, this piece of legislation does 

not include scholarship support or funding for those individuals 

that are in hospital administration or, quite frankly, as an example, on the business side of the programs and the need that exists 

within the Indian health programs, both tribal, Federal and urban. 

Mr. Chairman, given the complexity of Medicare legislation 

alone, and the need to be able to fully explain to individuals in 

Indian country what their entitlements are when they’re eligible 

for Medicaid, requires a slightly different kind of professional working in the community and in these facilities. 

We believe your Committee and the Congress should consider 

these additional professionals as part of a health delivery team, not 

just the providers. 

Mr. GIBBONS. Well, Mr. Lincoln, section 124 of the bill makes the 

benefits of the scholarship program non-taxable. If this were to 

happen, would you be able to extend the amounts appropriated for 

this activity so you could increase the number of scholarships 

awarded and take into consideration some of these other programs? 

Mr. LINCOLN. Mr. Chairman, I very much appreciate your question. As we reviewed this bill, it became fairly apparent that this 

section 124 is something that we strongly support. It is my understanding that a similar provision exists for the Department of 

Defense programs and for the National Health Service Corps. We 

strongly believe this is an important aspect of this bill. 

18

Recent estimates have been given to me that it would increase 

the number of scholarships of about—I believe the number is between 75 and 100. That sounds like a small number, but given our 

need, it is a very important group where we could expand access 

to these programs. 

Mr. GIBBONS. Considering the fact that Congress did exempt the 

National Health Service Corps and the Department of Defense 

scholarship benefits from being taxed, doesn’t the Indian Health 

Service administer similar scholarship programs to that, like the 

National Health Service Corps or the Department of Defense, and 

are they tax-exempt, and if not, should they be tax-exempt? 

Mr. LINCOLN. Mr. Chairman, they are very similar programs. Obviously, the Indian health professions piece of the Indian Health 

Care Improvement Act expands on the one hand efforts to increase 

the number of Indian people in the health professions in hard-torecruit locations, and we believe our program should be treated in 

a similar manner as the National Health Service Corps. This piece 

of legislation does that. 

Mr. GIBBONS. I have just one final question for you, and it has 

to do with section 110 of the bill, which authorizes loan repayment 

programs, changing the existing law which would require Indian 

applications be funded first. 

Can you explain how the current authority works and is the 

amendment contained in section 110 the appropriate change for 

that? I would ask you to explain for the benefit of the Committee 

that issue. 

Mr. LINCOLN. In section 110, which is where the loan repayment 

program is described, and the various elements of the loan repayment program, the way the program currently works is that the 

current law requires the Indian Health Service to identify and 

prioritize, by profession, the hard-to-fill locations—actually, all the 

locations throughout the county. So we identify for the industry, as 

an example, all of the hard-to-fill locations and we rank them, 

where we are required by law to rank them. The same would be 

said of nursing, would be said of medicine and the other health 

professions that are covered by the legislation. 

Then we proceed to go forward and use our loan repayment program and give priority to individuals who are going to accept positions in those most difficult positions and locations to be filled. 

It is my understanding that this bill continues to require the 

Indian Health Service to do what I just described, to identify the 

most needy locations and to prioritize them, but it also requires 

two other things that are different. 

One of the things that it requires is the prioritization of American Indian and Alaska Native applicants for positions. It actually 

describes that, in doing this and providing this increased priority, 

it overrides—I think is the language that’s used in this legislation—it overrides the priority system that we are required to provide. 

The second thing that is required from my understanding of the 

legislation that is different is that it then establishes a second priority, a second way to look at the filling and awarding of these loan 

repayments. It gives priority to Indian health programs, tribal 

health programs and urban programs. 

19

The third priority is then given to other programs, and the way 

we are understanding the legislation is that that third group, if you 

will, will be those Indian Health Service employees and locations. 

So those are the differences between the current legislation and 

this current bill. 

It is our sense that Title I was created to do a couple of things. 

One of them was to fill the hard-to-fill locations. There are places 

in this country and Alaska, in the Northern Plains, the Southwest 

and other places, that are just extremely difficult to recruit health 

professionals to those locations, and then to keep them and retain 

them there. 

This bill, through its scholarship program, certainly emphasizes 

the creation of Indian health professionals, and we believe we have 

already seen recipients of the loan repayment program and others 

stay longer over time in their jobs than other individuals, so we believe there is a success story. 

We would ask that the Committee work with us in reviewing 

these provisions that you have just mentioned. There must be a 

way of accomplishing both, of increasing the number of American 

Indian and Alaska Native health professionals and at the same 

time filling these hard-to-fill locations. 

Mr. GIBBONS. Thank you very much, Mr. Lincoln. 

Does anybody else have questions? Ms. Christensen. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. Good morning. 

I am looking at some of the testimony from the next panel, and 

the representatives of the National Council of Urban Indian 

Health, the Navajo Nation, and also the National Indian Health 

Board all support 151, the elevation. 

A few of us were talking about this just last week. When we look 

back at David Satcher, for example, as Surgeon General, many of 

us feel that the strengthening of his tenure as Surgeon General 

really had a lot to do with the fact that he was Assistant Secretary 

as well as Surgeon General. 

Is it your sense that raising him to the Assistant Secretary 

would in any manner diminish his or her ability to carry out the 

responsibilities on behalf of tribal governments? I’m not sure why 

the Department does not support 151. Can you just help me better 

understand that? 

Mr. LINCOLN. I believe there is a sincere effort and a reasoned 

effort on behalf of the Secretary and the Department when it says 

the current Director of the Indian Health Service has more access 

to decisionmaking forums and decisionmakers than any other previous Director of the Indian Health Service. 

Again, I have had the privilege of being in Washington, D.C., 

originally from Navajo, for the last 10 to 11 years, so I have had 

the privilege of working directly as the Deputy Director for three 

Directors of the Indian Health Service—for Dr Everett Rhoades, for 

Dr. Michael Trujillo, and now for Dr. Charles Grim. I can unequivocally tell you that Dr. Grim has more access, enjoys more access and more participation with decisionmaking groups than either of the two previous Directors. 

I believe the Department and the Secretary sincerely believe that 

they are providing him with the kind of access not only to 

themselves but to the other agency heads that make decisions for 

20

funding. This Intradepartmental Council for Native American Affairs, that is mentioned in our testimony, is becoming a central 

group where the needs of Indian country are not only left at the 

doorstep of the Indian Health Service to solve and to meet, but now 

are included with the Administrator for SAMHSA, the Commissioner for the Food and Drug Administration and others. I truly believe the Administration, the Department and our Secretary, believe that in those ways they have opened up the door to Indian 

country already. 

Mrs. CHRISTENSEN. The Secretary won’t be there forever. The 

Council is a creation of the Secretary, and the interaction that now 

exists, which sounds exemplary, is not guaranteed. 

Wouldn’t this be a way to ensure that that same relationship to 

the other agencies would continue to exist, but even beyond that, 

increase the authority of the Director to influence what happens in 

SAMHSA? Because right now, yes, they are able to talk with them 

and are able to access them, but they are not able to influence how 

those agencies respond to the needs of the tribal governments and 

the tribes. 

Mr. LINCOLN. Two points, Congresswoman. One, the 

Intradepartmental Council for Native American Affairs is a statutorily created council. It is created within the Native Americans 

Act, where it identifies this group. 

What is unique about this group is that it is now operational. 

You’re correct, in that the Secretary and the Deputy Secretary have 

breathed life into this Council and have required that these other 

agency heads, like Mr. Curie of SAMHSA or Dr. Gerberding of 

CDC and others, to actually set on that Intradepartmental Council 

for Native American Affairs. So I believe the intradepartmental 

council will continue because of the statutory basis. 

But how any Secretary uses any council like this is at the discretion of the Secretary. I think it might be inappropriate for me to 

speculate in the future. I think it is more important for me to say 

that the access is exemplary now, and I think we will be able to 

measure the increased access to non-IHS, Department of Health 

and Human Services funds in a very objective way in the near future. 

Mrs. CHRISTENSEN. It would just seem to me that since you have 

established this, the best way to continue it would be to elevate 

that position. 

Thank you, Mr. Chairman. 

Mr. GIBBONS. Thank you. 

Miss Napolitano. 

Mrs. NAPOLITANO. Thank you, Mr. Chair. 

I’m going back to services, and under the provision of Title I, it 

would establish a Native American psychological research program 

at the University of North Dakota, and it would also provide substance abuse and mental health counseling and coordinate with 

tribal colleges and other universities to expand such services. That 

is a critical area in my thinking, in being able to deal with some 

of the issues that Native Americans and others face. 

Is that the only university that is being considered, because as 

you well know, our tribes are dispersed throughout the United 

21

States. How is that going to work with other universities for that 

expansion? The provision is not quite clear on that. 

Mr. LINCOLN. Thank you for the question. 

The Quentin N. Burdick centers—and there are a couple—that 

are at the University of North Dakota, certainly one of them is to 

increase Indian people into psychology programs. 

Another at the University of North Dakota, a long-standing program, is called the INMED program, which is designed to increase 

the number of Indian physicians throughout the Nation, a very successful program by the way. 

There are other programs throughout the Nation that we believe 

are necessary, especially in the area of psychology. The other behavioral health sciences, there is great need in Indian country. 

Mrs. NAPOLITANO. Sir, I know that. I am aware of that. What I’m 

asking is how is this going to be dispersed amongst the Indian 

tribes to be able to help them. I know they are established in North 

Dakota and other universities, but how are they going to avail 

themselves or how is that university going to be able to help all 

the different issues the tribes have? 

Mr. LINCOLN. Right now those universities have Indian students 

from all over the country, not just from that northern tier of States. 

So they have opened their doors. 

What I was going to say, Congresswoman, is that we believe in 

the Indian Health Service there is greater need for these kinds of 

programs in other geographic locations. We would want to work 

with the Committee to discuss with you where those locations 

would be most logical. 

The University of Colorado would be a good example where programs are being developed. The University of Washington has a 

certain number of programs that exist with that institution, and 

there are others. The University of New Mexico is another good example. We need to expand their efforts. 

Mrs. NAPOLITANO. I understand. That’s why I’m asking the question. California has a number of tribes. I don’t know which colleges 

or universities in California are rendering those services to which 

we can refer some of our Indian population that reside in our districts. So I’m wanting to find out how is this going to be expanded 

to help all the different tribes in the areas, because all of them, I 

would think without exception, have issues that can be dealt with 

under some of these titles. 

Mr. LINCOLN. We would be glad to explore this, and we would 

be glad to bring not only our scholarship people but our—if we’re 

looking at behavioral health, we will bring our Director of Behavioral Health and work with you and your staff. I think we can be 

a little more detailed at that point. 

Mrs. NAPOLITANO. I would appreciate it, Sir. I am the Co-Chair 

of the Mental Health Caucus, and that’s one of the reasons I’m asking. Thank you. 

Mr. LINCOLN. Thank you. 

Mr. GIBBONS. Thank you. 

Mr. Pallone. 

Mr. PALLONE. Thank you, Mr. Chairman. 

Let me start out by saying I appreciate the fact that the 

Committee is having this hearing today, because when we had the 

22

joint hearing back with the Senate in the summer, one of the 

points that many of us made was that the Resources Committee on 

the House side needed to have some hearings on its own on the 

issues of the Indian Health Care Improvement Act, because it is 

such an important bill to Indian country. I think it needs more attention by us on the House side. 

Keeping that in mind, though, although I appreciate that we’re 

having the hearing, I wanted to mention, Mr. Chairman, that it 

really is a hearing on two bills, both of which are important, and 

my understanding is that the hearing today is only on Title I of the 

Indian Health Care Improvement Act. I hope that means we’re 

going to have hearings on the other titles, and if you could pass 

that on to the ‘‘powers that be’’, I would appreciate it. 

Could I inquire, is that the case, or don’t we know yet? 

Mr. GIBBONS. I would have to ask the Chairman of the 

Committee on that question. 

Mr. PALLONE. All right. If we could pass that along, I think it 

is important to have hearings on the other titles. But I do appreciate that we’re doing this today. 

What I wanted to ask Mr. Lincoln is by way of background. First 

of all, I wanted to say that our Congresswoman Christensen and 

Congresswoman Hilda Solis did a great job of putting together this 

health disparities legislation that the Democrats are going to introduce in the next couple of weeks. I want to commend them again 

for doing that because I think it relates directly to Indian country. 

Although it deals with a number of other minorities, it does relate 

directly to Indian country. 

An important part of that bill, one of the principles that they put 

forward in this Democratic initiative, is the need to diversify the 

health care workforce and to increase the number of minorities, be 

they Native American or whoever, that are involved in delivering 

health services. The main reason they say that is because they believe, at least from what they tell me, that if you have a diversified 

workforce and you have more Native Americans involved, then it 

just means in the long run not only better quality but also more 

attention is going to be devoted to the issue in some fashion. So I 

think that Title I is very important in that regard. 

There are so many questions that I have about Title I, let me 

just ask you these. First of all, do you support Title I and do you 

support the larger Indian Health Care Improvement Act, in general? 

Mr. LINCOLN. Yes, we do. 

Mr. PALLONE. OK. That’s very important because I think it’s a 

good bill and I am one of the cosponsors of it. So I appreciate that. 

I believe there is a crisis, not only in Indian health care in general, the quality of the delivery of services, but also a crisis in 

terms of lack of personnel who are Native American, or even personnel in general. The numbers are unbelievable from what I have 

seen. 

I guess my question is, I believe that this bill accomplishes a 

great deal in terms of moving in the proper direction, but I wanted 

to ask you about the specifics in terms of what we’re trying to 

achieve. Obviously, we need more Native Americans who are 

nurses and doctors, but we also need a lot more people in Indian 

23

country at the IHS hospitals and clinics in addition, whether 

they’re Native American or not, it seems to me. The problem is not 

only in terms of recruiting people and having adequate scholarships, but also making them stay in some of these rural and remote 

areas. 

So if you could just answer questions about that. In other words, 

do you think we have done enough or that we’re making significant 

strides in terms of getting Native Americans to become health care 

professionals, as opposed to non-Native Americans? Do you think 

we need to emphasize more on just recruiting people to these remote areas, where it’s difficult to get people? Third, if you could 

comment on not only our ability to get people to enter these health 

professions, but also to stay there long term, because a lot of these 

things keep them there maybe for a couple of years but are they 

going to keep them there for a lifetime. 

I know that’s a lot. 

Mr. LINCOLN. Congressman, it’s a very, very complex question, 

and maybe I can break it down in a way that will describe support 

for the entirety of the Indian Health Care Improvement Act. But 

I will give you some data that is preliminary but I think important 

to address the issue of retention and how it might relate to Title 

I. 

The breadth of the Indian Health Care Improvement Act is necessary because if the objective is not just to provide medical care 

to individuals, but if the objective is to actually improve the health 

status of those individuals and the communities within which they 

live, and, if you will, Indian people in general, that’s a very complex task. That requires more than just a physician’s visit with an 

individual given an acute episode that’s going on. It’s incredibly important that that is dealt with, that visit is dealt with, in a culturally appropriate manner, and that the clinical outcome is what 

is desired. 

But the breadth of the Indian Health Care Improvement Act addresses, as an example, replacing these old, outdated facilities that 

exist in many locations throughout Indian country. I know you 

have visited Indian country, Congressman, and I think you may 

have seen some of the best and some of the worst at the same time. 

But this bill moves us forward relative to the infrastructure that 

is going to be necessary to provide health care services in this decade that we are now embroiled in. 

How does just that one example relate to increasing recruitment 

and retention? It is more likely that a physician or a nurse coming 

out of a medical school, a school of nursing, a school of dentistry, 

or a school of pharmacy, it is more likely they will come to a new 

facility, one where they can practice the kind of medicine that 

they’ve just been trained to practice in. So the idea of being able 

to recruit and retain somebody, the facilities have a bearing on 

that. 

We know that in our newer constructed facilities the likelihood 

of somebody staying there is greater than if you’re isolated and you 

don’t have the proper staff support, and you’re in a building and 

you don’t have the equipment that you need. It is just a common 

sense kind of thing. 

24

Second, the Indian Health Care Improvement Act, as we think 

about it in the way it focuses resources and the delivery of health 

services themselves, the way it prioritizes those services, I think 

paints an honest picture of what the health status of Indian people 

is throughout this country, and the kind of interventions that 

might make sense, both in terms of the basic health care program, 

focusing on primary care services, ambulatory care within that, it’s 

the kind of a practice that we need to be honest about. 

That’s what people are going to see. Eight million outpatient visits this last year, that’s what you’re going to see when you deliver 

health care, and you’re going to see an array of women’s health 

issues, you’re going to see an array of issues of youth. The leading 

cause of death for Indian people between 5 and 45, the highly productive years of young people, are injuries due to automobile collisions. I purposely do not use the word ‘‘accidents’’ because they’re 

rather predictable. If you go out on Friday night and you drink to 

excess, and you drive on a road that is 50 or 60 miles, narrow and 

unlit—I’m speaking for our engineers at the moment—it’s pretty 

predictable that the accidents and death mortality is going to be 

high because people are young and driving fast, and they’re driving 

on roads that aren’t well lit, and they may be intoxicated. 

If you look at our data and really use the statistics in the way 

they’re supposed to be used, and the way the full bill allows us to 

analyze, you will come to the conclusion that these deaths due to 

automobile collisions are not merely accidents. They are not acts of 

God. You can predict them. Maybe you can’t predict the moment, 

but you can describe that they’re going to occur on Friday and Saturday evenings, late in the evening, and they’re going to occur as 

a result of somebody who is tired or somebody who has abused alcohol or some other drug. 

This bill, I believe, provides the needed specificity for describing 

how the Federal Government, working in partnership with tribes, 

can intervene to improve their health status. I truly believe that, 

Congressman Pallone. 

I also believe that this bill, with additional work, working in collaboration with tribes, the Department, our sister agencies, and the 

Department of Transportation and the Department of Housing and 

Urban Development, et cetera, can truly make a difference. I believe this bill needs some additional work and we’re prepared to 

join the Committee, along with the tribes, in doing that work. 

Mr. PALLONE. Thank you very much. 

Mr. GIBBONS. Thank you very much, Mr. Pallone. 

Mr. Lincoln, thank you very much for your testimony here today 

before the Committee. It’s been very enlightening. With that, we 

will excuse you and call up our third panel today. 

Mr. LINCOLN. Thank you, Mr. Chairman. 

Mr. GIBBONS. The third panel will be President Joe Shirley, Jr., 

from the Navajo Nation; Anthony Hunter, President, National 

Council of Urban Indian Health; and Julia Davis-Wheeler, CoChair, National Indian Health Board. 

Before you all take your seats, let’s me once again swear you in, 

as is the policy of this Committee. 

[Witnesses sworn.] 

25

Let the record reflect that each of the witnesses responded in the 

affirmative. 

With that, I am going to turn to my colleague from Arizona, Mr. 

Renzi, to introduce one of the witnesses. Mr. Renzi. 

Mr. RENZI. Thank you, Mr. Chairman. 

I have the distinct pleasure today to welcome from the largest 

Native American Nation America, the President, Mr. Joe Shirley, 

Jr. He is our new President of the Navajo Nation, of a proud and 

honorable people, a people who have served this Nation particularly given the times we’re in and in times of war, a nation of fighting men and women. I am grateful and honored to have you here 

today, sir. 

His experience is vast, not just in public service but in the field 

of social service, helping particularly children in the Navajo Division of Social Services, where he served as Executive Director. He 

helped in Northern Arizona as our Apache County Supervisor in 

1984, where he retired and recently ran for office and won, overwhelmingly, upon the Navajo Nation. His leadership and his passion is well-known throughout all of Northern Arizona, as well as 

the Southwest. 

President Joe Shirley, I am honored to have you here today. 

Thank you for coming all the way and making this trip. 

Mr. Chairman, thank you for the time. 

Mr. GIBBONS. Thank you, Mr. Renzi. With that, we will turn to 

each of our witnesses here today and thank them for their appearance. We will begin with Mr. Shirley. Welcome. 

STATEMENT OF HON. JOE SHIRLEY, JR., PRESIDENT, THE 

NAVAJO NATION, ACCOMPANIED BY ANSIEM ROANHORSE, 

JR., EXECUTIVE DIRECTOR, NAVAJO DIVISION OF HEALTH 

Mr. SHIRLEY. Thank you, Chairman, Congressman Renzi. It is an 

honor to be here before you and other distinguished members of 

the Committee on Resources. Thank you for allowing us to be 

heard today regarding H.R. 2440, the Indian Health Care Improvement Act Reauthorization Amendments of 2003. 

My name is Joe Shirley, Jr., President of the Navajo Nation. 

First, it is in the best interests of the Navajo Nation and other Native Americans that the 108th Congress reauthorize the Indian 

Health Care Improvement Act. The Act serves nearly 300,000 

Navajos residing on and off Navajo land. Native Americans, including the Navajos, have experienced severe disparities in health care 

and funding for it for many decades. This condition is contrary to 

the Federal Government’s trust responsibility to deliver and fund 

health care services based on treaties and legislation. 

The Navajo Nation, through a 15-member National Steering 

Committee put in place by the Indian Health Service, assisted with 

the development of a final agreement between tribes that was submitted to the Indian Health Service and the appropriate committees at the U.S. House of Representatives and Senate. 

The unmet health care needs of Native Americans are enormously high compared to the mainstream in the U.S. Heart disease 

is the number one killer among Navajo people. Health care disparities on Navajo land could be reduced by the improvement of bad 

dirt roads. Seventy-eight percent of our roads are dirt. Tribal 

26

members, including the elderly, children and the disabled, often 

must travel hundreds of miles to receive specialized care. Improved 

roads can mean the difference between life and death. Bad roads, 

combined with our inadequate communications network, and insufficient funding and resources for health care, increase the health 

care disparities. 

Further, there is a severe Navajo land nursing and dentist shortage. In Fiscal Year 2003, the Indian Health Service awarded 130 

Indian Health Service scholarship awards. By expanding Title I, it 

would help address the challenges with recruitment and retention 

of direct health care and specialized providers for the most isolated, 

rural and remote Native American communities. 

The Navajo Nation supports a fully funded Indian Health Service 

scholarship program for a wider range of health care disciplines to 

be implemented through area offices, not through the Indian 

Health Service’s headquarters office. Working with our area offices 

allows for a better understanding of the needs of our communities. 

This is especially valuable to Navajo communities where English is 

not the only spoken language. Knowledge of our Navajo language, 

culture and history is vital to communication. 

Further, the Navajo Nation supports section 216, which designates the State of Arizona as a contract health service delivery 

area for the purpose of providing contract health care services to 

members of federally recognized tribes in Arizona. Considering the 

high number of Navajos living in urban areas throughout the State 

of Arizona, and due to their need for quality health care, the 

Navajo Nation recommendations that section 216 be adequately 

funded. 

Further, Title III would require the Secretary of Health and 

Human Services to consult with tribes to determine tribal preferences during facilities construction. Consultation with tribes is 

absolutely necessary. Moneys earmarked for facilities construction 

costs need to be spent in ways that are consistent with tribal needs 

and preferences. Additional costs are incurred when corrective actions are undertaken for inconsistencies. 

Further, section 301(c) establishes a health care project priority 

system that is based upon need. The methodology creates a priority 

listing. The top ten priority inpatient care facilities, outpatient facilities, and specialized care facilities will be listed, along with justifications, costs and methodologies. The Navajo Nation supports 

this provision because it provides for a government-to-government 

consultation with tribes and establishes a criteria system that addresses the greatest needs first. 

The Navajo Nation requests that those projects currently in 

phase three of the existing Indian Health Service health facilities 

construction priority system be grandfathered and integrated into 

any new proposed facilities priority system. This is critically important for the Navajo Nation, as it has five projects currently in 

phase three. 

Further, the Navajo Nation boundaries span across three 

States—Arizona, New Mexico and Utah, and three Federal regions 

and 13 counties. It is estimated that over 80,000 Native American 

beneficiaries in the Navajo area are eligible for Medicaid, and the 

majority are members of the Navajo Nation. Currently, Navajo inVerDate 0ct 09 2002 13:22 Mar 26, 2004 Jkt 088533 PO 00000 Frm 00030 Fmt 6633 Sfmt 6602 J:\DOCS\89608.TXT HRESOUR1 PsN: KATHY
27

dividuals in three States seeking medical assistance from State 

Medicaid programs are subjected to three different sets of rules. It 

is for this reason that the Navajo Nation is planning to establish 

the Navajo Nation Medicaid Agency, which would also be more culturally relevant. 

Section 414 of Title IV would authorize the Navajo Nation as a 

single state agency for purposes of providing medical assistance to 

eligible Native Americans residing within the boundaries of the 

Navajo Nation. The Navajo Nation Medicaid Agency intends to 

streamline the various requirements and procedures for eligibility, 

payments, and other functions. 

Further, Title V would expand health care assistance for Native 

Americans residing in urban areas. The Navajo Nation supports 

Navajo people residing off Navajo land. Navajos are often forced to 

relocate to urban settings in order to pursue education or employment, and many end up without proper health care. 

Still further, most Native American communities suffer from 

health and social problems related to alcohol and substance abuse. 

As a result, the Navajo Nation supports a comprehensive treatment 

model for behavioral health which addresses substance abuse and 

mental health disorders. Title VII provides a more effective assessment and treatment of an individual in a holistic manner and offers comprehensive care in one department which prevents further 

referral of a client to several agencies for services. 

Still further, the Navajo Nation supports the establishment of a 

25-member National Bipartisan Commission on Indian Health 

Care to study the provision of health care as an entitlement to Native Americans. Health care as an entitlement would serve as a 

mechanism to improve the delivery of health care services to Native Americans. 

Last, regarding H.R. 151, the Navajo Nation supports the elevation of the Director of the Indian Health Service to an Assistant 

Secretary within the Department of Health and Human Services. 

Thank you. I have Mr. Ansiem Roanhorse, Jr. here with me to 

help answer questions, if there are any questions. Thank you, gentlemen. 

[The prepared statement of Mr. Shirley follows:]

Statement of Joe Shirley Jr., President, The Navajo Nation 

Introduction 

Mr. Chairman, Mr. Vice Chairman and distinguished members of the Committee 

on Resources, thank you for allowing us to present today: 

My name is Joe Shirley Jr., President of the Navajo Nation. On behalf of the 

Navajo Nation, we are honored to testify on H.R. 2440, the Indian Health Care Improvement Act Reauthorization Amendments of 2003 (‘‘Act’’). We firmly believe that 

it is in the best interest of the Navajo Nation and other American Indians and Alaska Natives that the 108th Congress reauthorizes the Indian Health Care Improvement Act. While the Navajo Nation supports the majority of H.R. 2440, we recommend that minor amendments be made to this Act in order to better address the 

needs of the Navajo Nation. 

The United States Congress enacted the Indian Health Care Improvement Act in 

1976 to provide a comprehensive and integrated approach to elevate the health status of American Indians and Alaska Natives to the highest level. The Act has been 

reauthorized four times over the past 27 years with the most recent reauthorization 

in 1992. The Act provides authority for appropriation of funding for the following: 

1) health professional development; 2) clinical care; 3) preventive health services; 4) 

facility construction and maintenance of community sanitation improvement; 5) 

recovery of health care cost from Medicare and Medicaid; 6) urban Indian health 

28

programs; 7) provision of mental health, alcohol and substance abuse, and domestic 

violence programs; and 8) establishment of a 25-member National Bipartisan Commission to study the provision of health care to American Indians and Alaska Natives as an entitlement. 

Over the past several years, in preparation for the reauthorization of the Indian 

Health Care Improvement Act, the Indian Health Service formed a 15-member 

‘‘437’’ National Steering Committee and sponsored a series of Area-wide, Regional, 

and National Tribal Consultation meetings to discuss specific health care concerns 

in Native communities and to make recommendations regarding the reauthorization 

of the Act. The Navajo Nation staff actively participated in the ‘‘437’’ National Steering Committee work and assisted with development of the final proposed ‘‘consensus 

bill’’ that was submitted to the Indian Health Service and appropriate committees 

of the United States House of Representatives and the United States Senate. 

The Act is critical for purposes of providing health care to over 1.6 million federally recognized American Indians and Alaska Natives through direct Indian Health 

Service, tribal, and urban Indian health programs. The Act serves over 295,000 

Navajo individuals residing on and off the Navajo reservation. American Indians 

and Alaska Natives, including the Navajo people, have experienced severe disparities in health care, funding and other resources for many decades. This condition 

is contrary to the federal government’s trust responsibility to deliver and fund 

health care services to the American Indians and Alaska Natives based on treaties 

and subsequent legislation. 

Although the Indian Health Service is severely underfunded, the Navajo Area 

Indian Health Service has made some positive strides improving the health status 

of the Navajo people in certain areas. According to the Navajo Area Indian Health 

Service data, the health status of the Navajo people is better than the general U.S. 

population in the following areas: 1) cancer deaths particularly breast cancer deaths; 

2) heart disease deaths; and 3) low weight births. However, the federal funding for 

Indian health care has not kept pace in the following factors: 1) medical and overall 

inflation; 2) rising costs of health care; 3) increasing costs of pharmaceuticals; and 

4) offering of competitive salaries and benefits to recruit and retain qualified health 

care professionals. According to the Indian Health Service Level of Need Funded 

Methodology, the Navajo Area Indian Health Service receives funds to meet only 54 

percent of the health needs of the patient population, and it provides health care 

services at $1,187 per person while the national average is about $3,582 per person. 

The unmet health care needs of the American Indians and Alaska Natives are enormously high. 

Comments and Recommendations 

Title I 

The Navajo Nation recognizes, as does the federal government, the severe nationwide nursing shortage. The Navajo Nation believes that education is the foundation 

for a strong, stable and accountable sovereign tribe. In 2002, the Navajo Nation received over 13,170 applications for tribal scholarship from aspiring Navajo youth 

who wanted to pursue post secondary education. The Navajo Nation provided scholarship support for only 5,920 applicants and had to turn down over 7,200 Navajo 

students due to limited tribal resources. Additionally, about 130 Navajo students received Indian Health Service scholarship awards in Fiscal Year 2003. By expanding 

Title I, the Navajo Nation can get culturally proficient health care providers thereby 

increasing health care professionals. Further, the expansion of Title I will begin to 

address the challenges with recruitment and retention of direct health care providers for the most isolated, rural and remote American Indian and Alaska Native 

communities. Thus, the Navajo Nation continues to support a fully funded Indian 

Health Service scholarship opportunity, through the Area Office, that funds a wider 

range of health care disciplines. The Navajo Nation recommends that a greater degree of flexibility and autonomy be provided to the Indian Health Service, tribes and 

urban Indian health programs to implement Title I. The Navajo Nation appreciates 

the intent of Title I, which is to increase opportunities for Indian people so that they 

may return home and become health care providers. This is particularly valuable 

to American Indian and Alaska Native communities like the Navajo Nation where 

English is not the only language spoken. The Navajo population includes both traditional and non-traditional people, some of whom speak only Navajo, who need 

health care providers knowledgeable in Navajo culture, history and language. The 

Navajo Nation supports efforts where Indian people are educated in health carerelated fields and are allowed to return to their communities. 

29

Title II 

This Title focuses upon various health initiatives. The Navajo Nation has special 

interest in Section 215. This section calls for the study and monitoring of programs 

to determine trends that exist in health hazards posed to Indian miners and Indians 

on or near reservations and in Indian communities as a result of environmental hazards that may result in chronic and or life-threatening diseases. The Navajo Nation 

further supports the inclusion of studies with summaries of findings, reports and 

plans of action. In addition to the provision of Section 215, the Navajo Nation supports compilation of accurate data regarding environmental health issues among 

Navajos, along with components for education, prevention and treatment while requiring entities charged with causing the health problems to take responsibility and 

rectify the damages. 

Section 216 designates the State of Arizona as a contract health service delivery 

area for the purpose of providing contract health care services to members of federally-recognized Indian tribes of Arizona. Considering the high number of Navajos 

living in urban areas throughout the State of Arizona and due to other need for 

quality health care, the Navajo Nation encourages Congress that Section 216 be 

adequately funded so that it can be properly implemented. 

Title III 

This Title focuses on funds spent on construction and/or renovation of Indian 

Health Service facilities. According to this Title, the Secretary of Health and Human 

Services shall consult with any Indian tribe that is significantly affected by the facilities expenditure for the purpose of determining and honoring tribal preferences 

concerning that facility. This type of consultation is absolutely necessary. 

Without tribal input regarding the undertaking of any construction and renovation of facilities, there exists a concern regarding self-determination. Also, there is 

a concern that monies earmarked for such construction costs will not be spent in 

ways that are inconsistent with tribal needs or preferences and that additional expenses will be incurred when efforts to correct these issues are undertaken. 

Section 301(c) establishes a health care project priority system that is based upon 

need. The proposed methodology is to create a priority list for planning, design, construction and renovation needs. Thereafter, the top ten priority inpatient care facilities, outpatient facilities and specialized care facilities will be listed, along with justifications, costs and methodologies. The Navajo Nation supports this proposal because it: 1) provides for government-to-government consultation with tribes; and 2) 

establishes a criteria system that addresses the greatest needs first. The Navajo Nation recommends that those projects currently in Phase III of the existing Indian 

Health Service Health Facilities Construction Priority System be ‘‘grandfathered’’ 

and integrated into any new proposed facilities priority system. This is of particular 

importance for the Navajo Nation, as the Navajo Nation has five projects in Phase 

III, including one alternative rural hospital in Kayenta, Arizona; three health centers in Dilkon, Arizona, Pueblo Pintado, New Mexico, and Bodaway/Gap, Arizona; 

and a new hospital in Gallup, New Mexico. Technical assistance from the Indian 

Health Service is critical to place these projects on the national funding list. 

The Navajo Nation is seriously concerned with Section 302(c)(3)(A). If this provision were approved, it would gravely widen an already massive backlog of homes 

to be served with adequate sanitation facilities. Although, despite the availability 

of amenities, such as running water and electricity, in the majority of homes in the 

U.S., a home without proper sanitation facility is an all too common reality, especially on the Navajo Nation. In fact, 31.9% of homes on the Navajo Nation lack proper plumbing facilities. The Navajo Nation recommends that the U.S. Congress provide for proper sanitation facilities in all new and existing homes on or in American 

Indian and Alaska Native communities and homes in order to achieve good public 

health outcome and to elevate the health status of American Indians and Alaska 

Natives to the highest possible level, without adversely affecting the funding source 

of future and existing Indian Health Service programs. 

Title IV 

The Navajo Nation boundaries span across three states (Arizona, New Mexico and 

Utah), three federal regions and 13 counties. It is estimated that over 80,000 American Indian beneficiaries in the Navajo Area are eligible for Medicaid and the majority are members of the Navajo Nation. It is for this reason that the Navajo Nation 

is planning to establish the Navajo Nation Medicaid Agency. 

Section 414 of Title IV would authorize the Navajo Nation as a Single State Agency for purposes of providing medical assistance to eligible American Indians and 

Alaska Natives residing within the boundaries of the Navajo Nation. Currently, on 

the Navajo Nation, there are three sets of rules with respect to Medicaid services—

30

one from the State of Arizona, New Mexico and Utah. The Navajo Nation Medicaid 

Agency intends to streamline the various requirements and procedures for eligibility, payments and other functions. The Navajo Nation anticipates that the medical services will be more culturally relevant to the Navajo population. 

Title V 

This Title is to expand health care assistance for American Indians and Alaska 

Natives relocated to, and residing in, urban areas. The Navajo Nation fully supports 

Indian people residing in off-reservation locations. These individuals are often forced 

to relocate to off-reservation settings in order to pursue education or employment 

and many end up without proper health care. 

Title VII 

The health and social problems related to alcohol and substance abuse continue 

to rise and affect the lives of many Navajo youth, adults and their families. It is 

estimated that about 25%, or about 44,843, of the total Navajos residing on the 

Navajo reservation have alcohol and substance use, abuse and addiction problems. 

Approximately 35% of the total Navajo population or 35,137 between the ages of 10 

and 17 are in the high-risk group, having been exposed to alcohol and substance 

abuse problems. It is also estimated that about nine of ten or about 161,434 Navajo 

individuals of all ages are affected by alcohol, substance abuse and other related behavioral health problems. About 50% or 20,000 individuals that are impacted by alcohol and substance abuse are not receiving any services. Due to lack of adequate 

funds and resources, the Navajo Nation Department of Behavioral Health Services 

(‘‘Department’’) is unable to provide service to a large number of high-risk youths 

and young adults. The Department does provide treatment and counseling services 

to about 19,000 patients every year. Information and education on alcohol and substance abuse is provided to about 20,000 individuals and families every year and 

another 14,000 individuals receive prevention, education, treatment and after care 

services through contracts with other providers. The Tribal Department delivers 

these services through its 10 outpatient treatment centers, three residential treatment centers, four mobile and outreach programs, and five mental health case management offices. 

The occurrence of mental health problems and disorders affects 35% of the total 

Navajo Nation population between the ages of 15 and 54. About 13 % of the total 

children and youth aged 9-17 experience serious emotional disturbance and one in 

five children and youth may have a diagnosable mental, emotional or behavioral 

problem. Prevalence of major depression among adults aged 45-64 is 2.3% of the 

total population. It is important to note that co-occurrence of mental and addictive 

disorders affect the Navajo population. About 37% of the total population with alcohol abuse are also diagnosed with a mental disorder and 53% of the other drug 

abusers have diagnosed mental disorders as well. 

The Navajo Nation staff worked closely with the ‘‘437’’ National Steering Committee and assisted with development of a seamless and comprehensive treatment 

model for behavioral health that is inclusive of substance abuse and mental health 

disorders. This new model was incorporated in Title VII and it will provide a more 

effective way of assessing and treating an individual in a holistic manner and offering comprehensive care in one department, which prevents further referral of a client to several agencies for services. 

Title VIII 

The Navajo Nation supports the establishment of a 25-member National Bipartisan Commission on Indian Health Care Entitlement to study the provision of 

health care to American Indians and Alaska Natives as an entitlement. This provision serves as a mechanism to improve delivery of health services to American 

Indians and Alaska Natives and, as such, the Navajo Nation firmly supports it. 

Conclusion 

On behalf of the Navajo people, I proudly present our concerns and recommendations to the members of the Committee as a testament to the continual need and 

improvement to the health and welfare of the Navajo people. Your support and consideration in the area of education, health care reform and self-determination is appreciated. Upon the passage of H.R. 2440 and S. 556, the Navajo Nation hopes that 

the Indian Health Care Improvement Act fulfills its intent to eliminate the health 

disparities plaguing Indian Country, thereby enhancing the ability of the Indian 

Health Service, tribal governments and urban Indian health programs to provide efficient health care services. Mr. Chairman, this concludes my testimony. Thank you 

for the opportunity to make my statement about the Indian Health Care 

31

Improvement Act Reauthorization of 2003. We will gladly answer any questions that 

you may have. 

Mr. GIBBONS. Thank you very much, Mr. Shirley. 

We now will turn to Mr. Anthony Hunter, President of the National Council of Urban Indian Health. Mr. Hunter. 

STATEMENT OF ANTHONY HUNTER, PRESIDENT,

NATIONAL COUNCIL OF URBAN INDIAN HEALTH 

Mr. HUNTER. Good morning, Mr. Chairman. Thank you, members 

of the House Resources Committee. 

I am also a member of the Shinnecock Nation of Eastern Long 

Island, as well as current President of the National Council of 

Urban Indian Health, which we affectionately refer to as NCUIH. 

On behalf of NCUIH, I would like to express our appreciation for 

this opportunity to testify before the Committee on H.R. 151 and 

2440. 

Founded in 1998, NCUIH is the only national organization representing urban Indian health programs. Our programs operate in 

41 cities and are often the main source of health care and health 

information for urban Indian communities. According to the 200 

Census, 66 percent of American Indians now live off reservations, 

and almost all of those Indians live in urban areas. 

Over the past few years, the urban Indian health programs have, 

on average, received slightly more than 1 percent of the Indian 

Health Service budget. In 1976, Congress passed the Indian Health 

Care Improvement Act, and the original purpose of this Act was set 

forth in a contemporaneous House report, which was to raise the 

status of health care for American Indians and Alaska Natives over 

a period of 7 years, equal to a level equal to that enjoyed by other 

American citizens. 

It has been 27 years now since that commitment was made, and 

20 years since the deadline for achieving it has passed. And yet, 

Indians, whether reservation or urban, continue to occupy the lowest rung on the health care ladder, with the poorest access to 

America’s extraordinary health care system. 

How can this be changed? First, Indian people need a stronger 

voice in the health care debate. Too often, our views are literally 

drowned out in the din created by other health care interests. Elevating the position of Director of Indian Health Service to Assistant 

Secretary for Indian Health will greatly strengthen the voice of 

Indian country, whether in the halls of the Department of Health 

and Human Services, or the corridors of Congress, or wherever the 

health care debate occurs and decisions are made. NCUIH fully 

supports H.R. 151. 

Second, it is important to reauthorize the Indian Health Care 

Improvement Act. Overall, NCUIH supports H.R. 2440, but we 

have a number of important concerns that need to be addressed in 

the legislation before we believe it should be adopted into law. 

We have the following recommendations: Regarding Title I, the 

Indian Health Professions and Scholarship Program, we would like 

to thank Congress for its support in making the program available 

to State-recognized Indians. This will greatly broaden the base of 

Indian people going into that system. 

32

Urban programs are able to take advantage of this to the degree 

that we are funded to support health professionals. As you may 

know, some of our programs are outreach and referral programs, 

very small programs, a very limited number of health professionals 

available, and very limited funding. Also, the Federal tort claims, 

which is provided for in the Indian Health Care Improvement Act 

Reauthorization, would help to support urban programs being able 

to recruit and retain Indian health care professionals in their programs. 

We recommend that the policy statement be amended to restore 

key references to urban Indians. The congressional policy statement in the existing Indian Health Care Improvement Act specifically references both Indians and urban Indians, which are separately defined terms. However, the equivalent section of H.R. 2440, 

section 3, paragraphs (1) and (2), do not include a reference to 

urban Indians. Removing urban Indians from this important policy 

statement would imply that the Congress no longer considers the 

health status of urban Indians to be a national priority. This is a 

very important issue to us and we urge you to maintain the current 

policy of including both Indians and urban Indians in the policy 

statement. 

Second, to spell out the definition of Indian and Indian tribe. The 

definition of Indian has been substantially revised in H.R. 2440 

from current law, principally by separating out subdefinitions that 

chiefly apply to urban Indians. NCUIH accepts the definitions, but 

recommends that instead of defining Indian by referring to another 

statute, the Indian Self-Determination and Education Assistance 

Act, that the definition be spelled out. 

We have the same concern for the definition of Indian tribe. In 

Title I, section 123, we ask that urban programs be included in the 

chronic shortage demonstration projects. In section 127, we ask 

that urban programs be included in the development and technical 

assistance programs for community education. 

In Title II, we ask that urban programs be included in the Indian 

Health Care Improvement Fund and the catastrophic health emergency fund. Also in Title II, section 212, we ask that urban programs be rendered the same technical assistance regarding communicable and infectious diseases available to other IHS funded programs. In Title II, section 213, we ask that urban programs be eligible for home- and community-based services, public health functions, and traditional health care. 

Urban programs do not participate in the IHS facility priority 

system established in Title III, which concerns facility construction, 

maintenance, and enhancement. A good facility is a key part of a 

good program and we ask for your consideration and including 

urban programs in this title. 

Title V is the urban title of H.R. 2440, which we strongly support. We would like to emphasize particular support for section 

512, which makes the Oklahoma City and Tulsa clinic demonstration programs permanent. These two projects have been very successful, and that success is justification for making them permanent. 

In conclusion, the entire Indian population, both reservation and 

urban, is deserving, morally and legally, of support from the 

33

Federal Government in achieving the highest level possible of 

health care. In my written testimony I have described at length the 

Federal trust responsibility as it applies to all Indians. NCUIH 

does not believe that this obligation stops at the reservation boundary. As much as their reservation counterparts, urban Indians have 

been affected by Federal programs and policies, including the BIA’s 

relocation program of over 160,000 Indians to cities between 1953 

and 1962, and the Federal policy of terminating tribes in the 1950s 

and 1960s. 

America is nowhere near the lofty goal set by Congress in 1976 

of achieving equal health care for American Indians. I challenge 

this Committee to think in terms of that goal as it considers 

H.R. 151 and H.R. 2440. NCUIH thanks the Committee for this 

opportunity to provide testimony on those bills. 

Thank you. 

[The prepared statement of Mr. Hunter follows:]

Statement of Anthony Hunter, President,

National Council of Urban Indian Health 

Introduction 

Honorable Chairman Pombo and Committee Members, my name is Anthony 

Hunter. I am the President of the National Council of Urban Indian Health 

(NCUIH) and a member of the Shinnecock Nation of Long Island, N.Y. I am also 

the Health Director for the American Indian Community House in New York City, 

N.Y. On behalf of NCUIH, I would like to express our appreciation for this opportunity to address the Committee on H.R. 151, the elevation of the position of the 

Director of the Indian Health Service within the Department of Health and Human 

Services to Assistant Secretary, and H.R. 2440, the Indian Health Care Improvement Act Amendments of 2003, and how they impact American Indian/Alaska Natives living off reservation. 

Founded in 1998, NCUIH is a membership organization representing 34 urban 

Indian health programs. Our programs provide a wide range of health care and referral services in 41 cities. Our programs are often the main source of health care 

and health information for urban Indian communities. In this role, they have 

achieved extraordinary results, despite the great challenges they face. According to 

the 2000 census, 66% of American Indians live in urban areas, up from 45% in 1970 

and 52% in 1980 and 58% in 1990. We expect that these percentages will continue 

to increase over the next ten years. It should be added that the American Indian 

population is widely considered the most undercounted group in the Census. Although the total number of Indians may actually be low, our experience is that the 

relative percentage of urban versus reservation Indians is accurate. Like their reservation counterparts, urban Indians historically suffer from poor health and substandard health care services. 

Federal Responsibility for Urban Indians 

As with Indian tribes, there is a specific Federal obligation to urban Indians. Congress enshrined its commitment to urban Indians in the Indian Health Care Improvement Act where it provided: 

‘‘That it is the policy of this Nation, in fulfillment of its special responsibility and legal obligation to the American Indian people, to meet the national goal of providing the highest possible health status to Indians and 

urban Indians and to provide all resources necessary to effect that policy.’’

25 U.S.C. Section 1602(a) (emphasis added). In so doing, Congress has articulated 

a policy encompassing a broad spectrum of ‘‘American Indian people.’’ Notably, as 

originally conceived, the purpose of the Indian Health Care Improvement Act was 

to extend IHS services to Indians who live in urban centers. Very quickly, the proposal evolved into a general effort to upgrade the IHS. See, A Political History of 

the Indian Health Service, Bergman, Grossman, Erdrich, Todd and Forquera, The 

Milbank Quarterly, Vol. 77, No. 4, 1999. 

Similarly, in the Snyder Act, which for many years was the principal legislation 

authorizing health care services for American Indians, Congress broadly stated its 

commitment by providing that funds shall be expended ‘‘for the benefit, care and 

assistance of the Indians throughout the United States for the following 

34

purposes:...For relief of distress and conservation of health.’’ 25 U.S.C. Section 13 

(emphasis added). Congress enunciated its objective with regard to urban Indians 

in a 1976 House Report: ‘‘To assist urban Indians both to gain access to those community health resources available to them as citizens and to provide primary health 

care services where those resources are inadequate or inaccessible.’’ H.Rep. No. 9-

1026, 94th Cong., 2d Sess. 18, reprinted in 1976 U.S. Cong. & Admin. News 

(USCAN) 2652, 2657. As noted above, in Acts of Congress, as well as in both Senate 

and House reports, there has been an acknowledgment of a Federal responsibility 

for urban Indians. 

The Supreme Court and other Federal courts have also acknowledged that there 

is a Federal responsibility towards Indians, both on and off their reservation. ‘‘The 

overriding duty of our Federal Government to deal fairly with Indians wherever located has been recognized by this Court on many occasions.’’ Morton v. Ruiz, 415 

U.S. 199, 94 S.Ct. 1055, 39 L.Ed.2d 270 (1974) (emphasis added), citing Seminole 

Nation v. United States, 316 U.S. 286, 296 (1942); and Board of County Commissioners v. Seber, 318 U.S. 705 (1943). In areas, such as housing, the Federal courts 

have found that the trust responsibility operates in urban Indian programs. ‘‘Plaintiffs urge that the trust doctrine requires HUD to affirmatively encourage urban 

Indian housing rather than dismantle it where it exists. The Court generally 

agrees.’’ Little Earth of United Tribes, Inc. v. U.S. Department of Justice, 675 F. 

Supp. 497, 535 (D. Minn. 1987). ‘‘The trust relationship extends not only to Indian 

tribes as governmental units, but to tribal members living collectively or individually, on or off the reservation.’’ Little Earth of United Tribes, Inc. v. U.S. Department of Justice, 675 F. Supp. 497, 535 (D. Minn. 1987) (emphasis added). ‘‘In light 

of the broad scope of the trust doctrine, it is not surprising that it can extend to 

Indians individually, as well as collectively, and off the reservation, as well as on 

it.’’ St. Paul Intertribal Housing Board v. Reynolds, 564 F. Supp. 1408, 1413 (D. 

Minn. 1983) (emphasis added). 

‘‘As the history of the trust doctrine shows, the doctrine is not static and 

sharply delineated, but rather is a flexible doctrine which has changed and 

adapted to meet the changing needs of the Indian community. This is to 

be expected in the development of any guardian-ward relationship. The increasing urbanization of American Indians has created new problems for 

Indian tribes and tribal members. One of the most acute is the need for 

adequate urban housing. Both Congress and the Minnesota Legislature 

have recognized this. The Board’s program, as adopted by the Agency, is an 

Indian created and supported approach to Indian housing problems. This 

court must conclude that the [urban Indian housing] program falls within 

the scope of the trust doctrine....’’

Id. at 1414-1415 (emphasis added). 

This Federal Government’s responsibility to urban Indians is rooted in basic 

principles of Federal Indian law. 

The United States has entered into hundreds of treaties with tribes from 1787 to 

1871. In almost all of these treaties, the Indians gave up land in exchange for promises. These promises included a guarantee that the United States would create a 

permanent reservation for Indian tribes and would protect the safety and well-being 

of tribal members. The Supreme Court has held that such promises created a trust 

relationship between the United States and Indians resembling that of a ward to 

a guardian. See Cherokee Nation v. Georgia, 30 U.S. 1 (1831). As a result, the 

Federal government owes a duty of loyalty to Indians. In interpreting treaties and 

statutes, the U.S. Supreme Court has established ‘‘canons of construction’’ that provide that: (1) ambiguities must be resolved in favor of the Indians; (2) Indian treaties and statutes must be interpreted as the Indians would have understood them; 

and (3) Indian treaties and statutes must be construed liberally in favor of the 

Indians. See Felix S. Cohen’s Handbook of Federal Indian Law, (1982 ed.) p. 221-

225. Congress, in applying its plenary (full and complete) power over Indian affairs, 

consistent with the trust responsibility and, as interpreted pursuant to the canons 

of construction, has enacted legislation addressing the needs of off-reservation 

Indians. 

The Federal courts have also found, that the United States can have an obligation 

to state-recognized tribes under Federal law. See Joint Tribal Council of Passamaquoddy v. Morton, 528 F.2d 370 (1st Cir. 1975). Congress has provided, not only in 

the IHCIA, but also in NAHASDA, that certain state-recognized tribes or tribal 

members are eligible for certain Federal programs. 25 U.S.C. Section 4103(12)(A). 

In sum, the Federal government’s trust obligation to protect American Indians 

does not stop at the reservation boundary. 

35

Federal Policy and the Development of Urban Indian Communities 

Urban Indian communities have principally developed as a result of misguided 

Federal programs or actions, such as the Bureau of Indian Affairs relocation program, which relocated 160,000 Indians to cities between 1953 and 1962. Today, the 

children, grandchildren and great-grandchildren of these Indians continue to reside 

in these cities. They maintain their tribal identity even if, in some cases, they have 

been unable to re-establish ties, including formal membership, with their tribes. 

While most, but not all, urban Indians are enrolled in federally recognized tribes, 

all are Indian descendants. Their circumstances are principally the result of Federal 

Indian policies; they are deserving, morally and legally, of support from the Federal 

government in achieving the highest possible health status. 

There are a number of Federal programs and policies which have led to the formation of the urban Indian population, including: • The BIA relocation program relocated 160,000 Indians to cities between 1953 

and 1962. Today, the children, grandchildren and great-grandchildren of these 

Indians are still in these cities; • The failure of Federal economic policies on reservations has forced many 

Indians to seek economic refuge in the cities; • The Federal policy of ‘‘terminating’’ tribes in the 1950s and 1960s, many of 

which have not yet been restored to recognition; • The marginalization of tribal communities such that they exist but are not federally recognized; • Indian service in the U.S. military brought Indians into the urban environment; • The General Allotment Act resulted in many Indians losing there lands and 

having to move to nearby cities and towns; • Court-sanctioned adoption of Indian children by non-Indian families; and • Federal boarding schools for Indians. 

Some of these federal policies were designed to force assimilation and to breakdown tribal governments; others may have been intended, at some misguided level, 

to benefit Indians, but failed miserably. One of the main effects of this ‘‘course of 

dealing,’’ however, is the same: the creation of an urban Indian community. 

Funding Inequities 

Since the first official funding for urban Indian health through the Indian Health 

Service in 1979, the urban Indian health program has received just over 1% of the 

total Indian Health Service annual appropriation (although, as noted above, 66% of 

Indians now live in urban areas). 

During the decade of the 1990s, Congress increased funding for urban Indian health by 113% from $13,049,000 in 1990 to $27,813,000 in 2000. During this same 

period, the number of Indian people moving to American cities was on the increase. 

Estimates from the 1990 census found that more than 1.3 million Indian people 

were living in American cities out of the 2.4 million people self-identifying at that 

time. The 2000 census shows that of the 4.1 million people self-identifying as American Indian or Alaska Native, 2.87 million are urban. Just like the on-reservation 

programs, urban Indian programs have experienced a constant increase in the demand for our services. In fact, the increase in the urban area is likely greater than 

the increase on the reservation. 

Throughout its history, the urban Indian health program has never received a 

substantial boost to its funding base. Annual increases offered by the Congress average only about $30,000 per program in new funding each year. While we are grateful for any and all new dollars allocated to Indian health, the reality is that urban 

programs are finding themselves with increasing numbers of people in need and a 

declining supplemental financial base to cover rising costs. As a result of this lessened funding, urban Indian programs can only service 95,767 of the estimated 

605,000 urban Indians eligible to receive services. 

For FY 05, the National Council of Urban Indian Health recommended a $6 million increase to the Urban Indian Health line item of the IHS budget. Subsequently, 

the Senate Committee on Indian Affairs recommended an increase to the urban 

Indian health program from its current proposed 2004 funding level of $32 million 

to $48 million, a 50% increase. NCUIH believes that an adjustment of $6 million 

or more would be an important step in reinforcing urban Indian health efforts for 

this nation. 

As Urban Indian Health Programs prepared for the FY05 Budget we have identified 19 program priorities of equal importance. These priorities are: 

1. Diabetes 

2. Cancer 

3. Alcohol and Substance Abuse 

4. Heart Disease 

36

5. Mental Health 

6. Maternal and Child Health 

7. Dental Health 

8. Injuries 

9. Elder Health 

10. Respiratory / Pulmonary 

11. Violence / Abuse 

12. Infectious Disease 

13. Hearing Disease 

14. Eye Disease 

15. Health Promo / Disease Prevention 

16. Tobacco Cessation 

17. Information Technology Support 

18. Maintenance and Repair 

19. Facilities and Environmental Health Support 

With the Urban Indian Health Program occupying only 1% of the total IHS Budget it is extremely imperative for urban programs to obtain supplemental funding to 

remain in operation. Urban Indian Health Programs access roughly $7 million in 

federal funds outside of the Indian Health Service. These funds include Sections 

229, 330, 340 of the Public Health Service Act, Maternal and Children’s Health 

Block grant, and Title V Public Health Care Service, and Women, Children and Infant Program, a supplemental of WIC. 

NCUIH acknowledges that there are some sound reasons why the lion’s share of 

the IHS budget should go to reservation Indians. However, we believe that the disparity is too great. All Indian people are connected. Disease knows no boundaries. 

There is substantial movement back and forth from reservation to urban Indian 

communities. The health of Indian people in urban areas affects the health of Indian 

people on reservations, and visa versa. We strongly believe that the health problems 

associated with the Indian population can be successfully combated only if there is 

significant funding directed at both the urban and reservation populations. 

Elevation of the Indian Health Service Director—H.R. 151

NCUIH strongly supports the elevation of the Director of the Indian Health Service to Assistant Secretary for Indian Health as provided for in H.R. 151. One reason 

why the status of Indian health has improved so slowly since Congress announced 

its commitment in 1976 is that Indian people do not have sufficient influence in the 

health care debate. Too often, our voices are literally drowned-out by the cacophony 

of other health care interests. For example, when we hear that the Director of IHS 

cannot attend certain meetings because of his lesser position, it is time for a change. 

Protocol should never come at the price of common sense and the health needs of 

Americans, Indian or otherwise. Elevating the position of the Director of Indian 

Health Service to Assistant Secretary for Indian Health will greatly strengthen the 

voice of Indian country, whether in the halls of the HHS, the corridors of Congress, 

or wherever the health care debate occurs and decisions are made. 

Indian Health Care Improvement Act 

In 1976, Congress passed the Indian Health Care Improvement Act. The original 

purpose of this act, as set forth in a contemporaneous House report, was ‘‘to raise 

the status of health care for American Indians and Alaska Natives, over a sevenyear period, to a level equal to that enjoyed by other American citizens.’’ House Report No. 94-1026, Part I, p.13 (emphasis added). 

The Senate has recognized that Congress also has an obligation to provide health 

care for Indians, that includes providing health care to those who live away from 

the reservation. 

‘‘The responsibility for the provision of health care, arising from treaties 

and laws that recognize this responsibility as an exchange for the cession 

of millions of acres of Indian land does not end at the borders of an Indian 

reservation. Rather, government relocation policies, which designated certain urban areas as relocation centers for Indians, have, in many instances, 

forced Indian people who did not [want] to leave their reservations to relocate in urban areas, and the responsibility for the provision of health care 

services follows them there.’’

Senate Report 100-508, Indian Health Care Amendments of 1987, Sept. 14, 1988, 

p. 25 (emphasis added). 

Although the road ahead to equal health care still appears to be a long one for 

Indians, including urban Indians, NCUIH believes H.R. 2440 is a step in the right 

direction. As a general matter, NCUIH supports H.R. 2440, although we do 

37

recommend certain changes to maintain Congress’ commitment to urban Indians in 

H.R. 2440. 

Definitions 

The definition of ‘‘Indian’’ has been substantially revised in H.R. 2440 from current law, principally by separating out sub-definitions that chiefly apply to urban 

Indians. NCUIH has accepted the new structure, but has recommended that instead 

of defining ‘‘Indian’’ by referring to another statute (ISDEAA), NCUIH believes that 

the definition should be spelled out for clarity’s sake. Therefore the definition should 

read: ‘‘The term ’Indian’ means a person who is a member of an Indian tribe.’’ This 

also avoids any concern that the definitional change is intended to incorporate other 

aspects of the ISDEAA. 

TITLE I 

SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION 

PROGRAMS. 

Under this section, urban programs are not eligible to apply for chronic shortage 

demonstration projects. Urban programs are not immune to the same chronic shortages of health professionals that IHS and Tribal Health Programs face. NCUIH 

urges amendment of this section to include the urban programs as possible sites for 

demonstration projects. 

SEC. 127. MENTAL HEALTH TRAINING AND COMMUNITY EDUCATION 

PROGRAMS. 

This section includes urban Indian programs in the study of mental health providers that will develop the training criteria for those providers. However, this section fails to ensure that urban Indian health providers are included in the development and technical assistance for community education. This is a concern because 

urban programs are often left out of training and technical assistance programs that 

are provided for tribal and IHS personnel. 

TITLE II 

Urban Indian Health Programs are not authorized in the current or proposed legislation in sections 201 and 202 to benefit from the Indian Health Care Improvement Fund (IHCF) or the Catastrophic Health Emergency Fund (CHEF). Lack of 

authorization for urban ICHF requires that urban programs divert funding from 

their current contracts to address community health needs or seek other funding 

sources outside of the Indian Health Service. If urban Indian health programs were 

authorized to access IHCF there would be more of a focus on development and provision of services to Indian patients versus the total patient population, which includes insured non-Indian patients who are seen in their clinic. IHCF for urban 

Indian health programs also would reduce the need for urban Indian health programs to diversify their funding sources to the extent that some programs have, e.g. 

one program has as many as 60 different funding sources. The administrative savings would benefit all urban Indian health programs. Currently, tribal members 

who reside in the New York metropolitan area, without any type of insurance, who 

have a catastrophic illness or are a victim of a disaster have only three options: 1. 

Seek care at their home reservation and wait for up to 6 months until the tribal/

IHS contract health care eligibility guidelines apply; 2. Apply for Medicaid and other 

indigent care insurance; or 3. Nothing. 

SEC. 212, PREVENTION, CONTROL, AND ELIMINATION OF COMMUNICABLE 

AND INFECTIOUS DISEASES 

This section includes urban programs in the consultation and reporting processes 

but limits project and technical assistance funding that is available to tribes and 

tribal organizations. We urge that this assistance also be extended to urban programs. 

SECTION 213

This section eliminates urban Indian health programs from authorization of funding for certain critical services, primarily home- and community-based services, public health functions and traditional health care. These services are highly needed 

within urban Indian health centers. Although, the urban population may not be located in an isolated rural community, a need exists to be able to provide in-home 

care to elderly and disabled persons who are not able to navigate the urban area 

due to lack of transportation or failing health. 

38

TITLE III 

This section is limited to facility construction, maintenance and enhancement. Unlike tribes and Indian Health Service, both current and proposed legislation does not 

permit urban programs to participate in the facility priority system for funding of 

health clinics. Several urban Indian health programs have either purchased or built 

their own facilities through commercial loans, capital improvement funds or utilization of third party revenue received. However, these types of funding are often difficult to secure and most times are not available to limited direct service and outreach/referral programs. A good facility ensures that the community has a stable location. Urban centers that lease are faced with increasing rental costs and no sense 

of ownership by the community. Programs that have had to move have found it very 

expensive and time consuming. 

TITLE IV 

This section speaks to the federal trust responsibility through the authorization 

to disregard payments received by tribes, tribal organizations and urban programs 

in determining funding appropriations for health care and services to Indians. In 

recent years Indian health programs have not received adequate funding to provide 

comprehensive services to Indian people. Although, it appears that appropriations 

have increased, these increases have not kept up with medical rate of inflation, general inflation increases, salary increases or population growth. 

This section also authorizes urban Indian health programs to recover reasonable 

charges for services for individuals who have private or public medical insurance. 

It is very important for urban health programs to receive reimbursement from 

health insurance, Managed Care Organizations, CHIP, Medicare and Medicaid 

when the Indian patient is enrolled with the plan, although urban Indian health 

organizations are considered to be an ‘‘out of network provider.’’

TITLE V 

Title V is the heart and soul of the IHCIA for the urban Indian health programs. 

This section creates 36 urban Indian health programs and 12 urban alcohol a.k.a. 

‘‘NIAAA’’ programs. This section also serves as the guidelines for creating other 

urban Indian health programs. 

Items of note include the ability of current programs to create satellite clinics to 

better address the health needs of the Indian community. This is vital because 

many programs are located in large metropolitan cities such as Los Angeles, San 

Francisco, Chicago or Denver and have a large concentration of Indian people in 

their area. 

Section 509 authorizes, for the first time, grants to urban programs for the lease, 

purchase, renovation, construction or expansion of these facilities. It also establishes 

a revolving facilities loan fund that will be used solely for the purposes of urban 

facilities. The proposed fund would be self-sustaining. Facilities funding is a great 

need for almost every urban Indian health program. An important note in this section is that the urban programs do not have access to funds for maintenance and 

improvement of their facilities. The program in Boston currently resides in a very 

old State institution that utilizes skeleton keys for some of its offices. 

Section 511 deals only with the issue of substance abuse; however throughout 

Title VII urban Indian health programs and urban Indians are included in this behavioral health section. Not to discount the substance abuse needs of urban Indians, 

it would better serve the urban Indians to be carried throughout Title VII because 

of its comprehensive look at both mental health and substance abuse issues for 

Indian people. 

NCUIH recommends that Section 512, the Oklahoma City and Tulsa Clinics provision, should be made permanent and not subject to the Indian Self Determination 

and Education Assistance Act. As you may know, the Oklahoma City and Tulsa 

Clinics have been very successful. That success is the justification for making these 

projects permanent. It is not, however, a justification for changing their status as 

urban Indian programs. While their success is an incentive for some to urge such 

a change, there is a real risk that a change, for no substantive reason, could unnecessarily jeopardize the success of these programs and undo all of their accomplishments. 

TITLE VIII 

The establishment of a National Bipartisan Commission on Indian Health Care 

Entitlement is welcome. Healthcare for Indian people must be viewed as an entitlement versus a discretionary program. 

39

Conclusion 

America is nowhere near the lofty goal, set by the Congress in 1976, of achieving 

equal health care for American Indians, whether reservation or Urban. It has been 

twenty-seven years since Congress committed to raising the status of Indian health 

care to equal that of other Americans, and yet, Indians, whether reservation or 

urban, continue to occupy the lowest rung on the health care ladder, with the 

poorest access to America’s vaunted health care system. NCUIH challenges this 

Committee to think in terms of that goal as it considers H.R. 151 and H.R. 2440. 

We believe that these legislative measures will result in the betterment of health 

for all Indian people regardless of where they live, and reduce health disparities for 

Indian people. NCUIH thanks this Committee for this opportunity to provide testimony. We strongly urge your positive action on the matters we have addressed 

today. 

Mr. RENZI [presiding]. Mr. Hunter, I want to thank you for your 

articulation. In speaking with staff, I want you to know that the 

silence on the definition as it relates to urban Indians is no intention to omit. You have our commitment that we will work with you 

now to fix it before markup, so that at markup the language will 

be included. 

I would ask that we please get together. I know there was representatives from the urban Indian association that were included 

in the beginning, and if we need to move forward with some technical changes, we are willing to do that, OK? 

Mr. HUNTER. Thank you. 

Mr. RENZI. You deserve it, you absolutely deserve it. 

We’re going to move now to Julia Davis-Wheeler, who is CoChair of the National Indian Health Board. Julia. 

STATEMENT OF JULIA DAVIS-WHEELER, CHAIRPERSON,

NATIONAL INDIAN HEALTH BOARD 

Ms. DAVIS-WHEELER. Good morning, distinguished members of 

the House Resources Committee. As stated, my name is Julia 

Davis-Wheeler, and I am Chairperson of the National Indian 

Health Board. I also serve as Co-Chair of the Steering Committee 

on the Indian Health Care Improvement Act. 

I would like to have the House Resources Committee also recognize another Board member that is with me, Chairwoman from the 

San Carlos tribe, Kathy Kitcheyan. She is sitting behind me. She 

is also a member of the National Indian Health Board. 

As I stated, the NIHB has served since 1972 all the federally recognized American Indian and Alaska Native governments in advocating for the improvement of Indian health care delivery to American Indians and Alaska Natives. 

I would like to speak to you about the elevation of the Director 

of the Indian Health Service to the Assistant Secretary level. I’m 

just going to say a few words before I do, though, about Secretary 

Tommy Thompson. 

As a tribal leader, I have publicly stated that I feel very comfortable in saying that Secretary Thompson has been a most accessible Cabinet Secretary in this Administration. He has made every 

effort possible to visit with tribal leaders. Just last month, he 

toured several villages throughout the State of Alaska and capped 

off his visit by hosting a listening session with tribal governments 

from the States of Alaska, Idaho, Oregon and Washington. 

40

Tribal leaders have long pushed for the elevation of the status 

of the Indian Health Service Director to the Assistant Secretary 

level. This has been going on for the past 6 years. The National 

Indian Health Board, as well as the National Congress of American 

Indians, have passed resolutions at our General Assembly sessions 

supporting this elevation. 

H.R. 151, elevating the Director, is quite appropriate. As stated 

earlier, it reflects the government-to-government relationship between the United States and the tribal governments. It is very important to Indian country that we are extremely hopeful that it finally is signed into law this year. The National Health Board supports H.R. 151 as it ensures American Indians and Alaska Natives 

that their health issues remain a priority beyond this current Administration. 

As we advance this legislation, we would like to take adequate 

steps to ensure that we build on the improvements that have been 

made within the DHHS over the past few years in addressing tribal issues, and further, that the Indian Health Service does not become isolated from other DHHS’s. We recommend that the legislation, indeed, places the IHS Director at the level of Assistant Secretary, but it do so in a manner which does not diminish the Secretary’s responsibilities to carry out the Federal Government’s 

trust responsibility. 

As I mentioned previously, over the past several years American 

Indians and Alaska Natives have slowly crept into the mindset of 

nearly all areas of DHHS. The raised awareness is attributable to 

several things, including the informed personnel within the office 

of the Secretary and the hard work of the DHHS officials to advance issues internally and, most importantly, the persistence of 

tribal governments to ensure that the purpose and intent of the Executive order mandating tribal consultation is properly carried out. 

One of the more significant examples of the increased awareness 

and acknowledgment of the importance of Indian issues within the 

Department is the revival of the Secretary’s Intradepartmental 

Council on Native American Affairs, which the Indian Health Service Director serves as vice-chair. We, as tribal leaders, feel that it 

is appropriate that H.R. 151 incorporate language that places the 

IHS Director as Chair or Co-Chair of the Secretary’s Intra-departmental Council on Native American Affairs. The IHS Director currently serves as Vice-Chair. 

Now I would like to speak to you on the Indian Health Care Improvement Act Reauthorization. I am going to be brief this morning. I realize that the Committee members are quite of the need 

and the purpose of the reauthorization. 

In addition to me as Chair of the National Indian Health Board, 

I stated earlier that I serve as Co-Chair of the National Steering 

Committee, with Rachel Joseph, Chairperson of the Lone Pine Paiute Shoshone Tribe. The National Ateering Committee was formed 

in 1999 to develop and submit recommendations for changes to the 

Indian Health Care Improvement Act. 

Over the last several years, the National Steering Committee has 

worked closely with American Indian and Alaska Native tribal 

leaders, the Administration, Congress and the Indian Health Service to develop amendments to the Indian Health Care Improvement 

41

Act. We have proceeded with this process in a spirit of cooperation 

and negotiation and the language has gone through numerous 

changes. The end product is the language of H.R. 2440. 

At this time I would like to discuss Title I, the Indian Health 

Human Resource Development. While other titles may garner more 

attention due to their potential fiscal impact, Title I addresses the 

critical need to increase the number of American Indian and Alaska Natives entering the health professions. Health care remains 

the top priority in Indian country. It is critical to the existence of 

our people. 

I see that the light is on. I just need to break away from my summation comments and let the House Committee members know 

here today that it is, indeed, a legislation that we feel as a national 

steering committee that we would truly and honestly like to see 

passed in the 108th Congress. 

I just flew in last night from St. Paul. The National Indian 

Health Board is having their conference there. Dr. Grim is at that 

meeting right now. I informed the assembly before I left that I was 

coming to testify. There is so much support from all of the American Indians and Alaska Native governments for this legislation. I 

impose on you to look at this legislation very carefully and to consider the under-funding that we, as tribal governments, have gone 

through for years and years, and give this legislation its proper 

passage. 

Thank you. 

[The prepared statement of Ms. Davis-Wheeler follows:]

Statement of Julia Davis-Wheeler, Chairperson,

National Indian Health Board, Council Member, Nez Perce Tribe 

Chairman Pombo, Ranking Member Rahall, and distinguished members of the 

House Resources Committee, I am Julia Davis-Wheeler, Chairperson of the National 

Indian Health Board. I am an elected official of the Nez Perce Tribe, serving as 

Council Member. On behalf of the National Indian Health Board, it is an honor and 

pleasure to offer my testimony this morning on efforts to elevate the Indian Health 

Service Director to the position of Assistant Secretary of Health and to reauthorize 

the Indian Health Care Improvement Act. 

The NIHB serves nearly all Federally Recognized American Indian and Alaska 

Native (AI/AN) Tribal governments in advocating for the improvement of health 

care delivery to American Indians and Alaska Natives. We strive to advance the 

level of health care and the adequacy of funding for health services that are operated by the Indian Health Service, programs operated directly by Tribal Governments, and other programs. Our Board Members represent each of the twelve Areas 

of IHS and are elected at-large by the respective Tribal Governmental Officials 

within their regional area. 

Indian Health Service Director Elevation to Assistant Secretary of Indian Health 

Before I begin discussing H.R. 151 to elevate the Indian Health Service Director 

to the position of Assistant Secretary of Indian Health, I would like to say a few 

words about the Secretary of Health and Human Services, Mr. Tommy G. Thompson. As a Tribal leader, I have publicly stated that I feel very comfortable in saying 

that Secretary Thompson has been the most accessible Cabinet Secretary in this Administration. He and his immediate staff have been available at every possible opportunity to visit with tribal leaders and to see firsthand the health needs of our 

people. Just last month, he toured several villages throughout the State of Alaska, 

and capped off his visit by hosting a listening session with Tribal governments from 

the States of Alaska, Idaho, Oregon and Washington. 

Also, the National Indian Health Board is very pleased to have Dr. Charles Grim 

serving as Director of the Indian Health Service (IHS). We have supported his nomination from the beginning and, in fact, our Vice Chair, H. Sally Smith, held the 

Bible that was used to swear-in Dr. Grim. We appreciate his willingness to take on 

42

such a significant role. He is actually in Saint Paul, Minnesota, today participating 

in our annual conference. 

Tribal leaders have long pushed for elevating the status of the IHS Director as 

a means to recognize the importance of the federal government’s functions in carrying out its trust responsibility to American Indian and Alaska Native Tribal governments. The intent of H.R. 151 is quite appropriate as it does just that in a manner consistent with the government-to-government relationship between the United 

States and Tribal governments. H.R. 151 is very important to Indian Country and 

we are extremely hopeful that it is finally signed into law this year. The National 

Indian Health Board is very supportive of H.R. 151 as it ensures American Indian 

and Alaska Native health issues remain a priority beyond this current Administration. 

As we advance this legislation, we want to take adequate steps to ensure that we 

build on the improvements that have been made within the Department of Health 

and Human Services (DHHS) over the last few years in addressing Tribal issues 

and further, that the Indian Health Service does not become isolated from other 

areas of DHHS. We feel that this can be accomplished with minor revisions to 

H.R. 151. 

We recommend that the legislation indeed places the IHS Director at the level of 

Assistant Secretary of Indian Health, but do it in a manner which does not diminish 

the Secretary’s responsibilities to carry out the federal government’s trust responsibility to Tribal governments. 

As I mentioned previously, over the past several years, American Indian and Alaska Native issues have slowly crept into the mind-set of nearly all areas of DHHS. 

They raised awareness and are attributable to several things, including the informed personnel within the Office of the Secretary, the hard work of DHHS officials to advance issues internally, and, most importantly, the persistence of Tribal 

governments to ensure that the purpose and intent of the Executive Order mandating Tribal consultation is properly carried out. 

One of the more significant examples of the increased awareness and acknowledgment of the importance of Indian issues within the Department is the revival of the 

Secretary’s Intradepartmental Council on Native American Affairs, which the 

Indian Health Service Director serves as Vice Chair. We feel that it is appropriate 

that H.R. 151 incorporate language that places the IHS Director as Chair of the 

Secretary’s Intradepartmental Council on Native American Affairs. 

Because of the many critical issues that need to be addressed within the Department of Health and Human Services, we feel that any changes to the structure of 

the Department must be done in a manner that does not isolate Indian health 

issues, but instead makes these issues a common thread among all Department 

areas. 

Indian Health Care Improvement Act Reauthorization 

Given the previous joint House and Senate hearing on the Indian Health Care Improvement Act, I’m going to be brief this morning. I realize the Committee members 

are quite aware of the need and purpose of the reauthorization; therefore I would 

like to focus on the efforts of Tribal leaders to craft H.R. 2440 in a way that addresses previous concerns raised by the Administration and responds to the current 

political realities facing Congress. 

National Steering Committee for the Reauthorization of the Indian Health Care Improvement Act (IHCIA) 

In addition to my position as Chair of the National Indian Health Board, I also 

serve as the Co-Chair of the National Steering Committee for the Reauthorization 

of the Indian Health Care Improvement Act (IHCIA). Rachel Joseph, Chairperson 

of the Lone Pine Paiute Shoshone Tribe, serves as the other Co-Chair. The NSC was 

formed by the Indian Health Service in 1999 to develop and submit recommendations for changes to the Indian Health Care Improvement Act. The NSC is comprised of elected tribal representatives throughout Indian Country, and also includes urban health program representation. 

Over the last several years, the NSC has worked closely with American Indian 

and Alaska Native Tribal leaders, the Administration, Congress, and the Indian 

Health Service to develop amendments to the Indian Health Care Improvement Act. 

We have proceeded through this process in a spirit of cooperation and negotiation 

and the language has gone through numerous changes. The end product is the language of H.R. 2440. 

As the Committee is well aware, funding for the Indian Health Service lags far 

behind other segments of the population and has failed to keep pace with population 

increases and inflation. Current Indian Health Service funding is so inadequate that 

43

less than 60 percent of the health care needs of American Indians and Alaska Natives are being met. In order to address the need for additional health care resources, Title IV of the Indian Health Care Improvement Act addresses access to 

Medicare, Medicaid and other third party reimbursements. It is one of the most important provisions of the Indian Health Care Improvement Act as it makes IHS hospitals eligible for Medicare reimbursements, and also makes IHS facilities eligible 

for Medicaid reimbursements. Title IV makes it possible for Medicare- and Medicaid-eligible American Indians and Alaska Natives to utilize these benefits. 

Since the passage of the Indian Health Care Improvement Act in 1976, Medicare 

and Medicaid payments have become vital sources of revenue for basic Tribal hospital and clinic operations. In FY 2002 alone, IHS and tribally operated hospitals 

and clinics collected $460 million for services provided to Indian people enrolled in 

these programs. This amount enhances the resources available for the IHS hospitals 

and health clinics budget by nearly 30%. 

In order to further improve the ability of Indian Country health providers to access third-party resources, the NSC developed several changes to Title IV that were 

included in S. 212 introduced during the 107th Congress. When asked to respond 

to the language contained in S. 212, several concerns were raised by Health and 

Human Services Secretary Tommy G. Thompson regarding the proposed changes to 

Title IV. The concerns were primarily related to costs. I would like to note that S. 

556, introduced during this Congress, is identical to S. 212 and therefore many of 

the concerns raised in regards to S. 212 remain. 

In response to those concerns, the National Steering Committee revised their recommendations for the reauthorization and those changes are reflected in H.R. 2440. 

I think it was quite helpful to hold the joint House Resources Committee and Senate 

Committee on Indian Affairs hearing in July as it illustrates the efforts of both 

houses to pass a bill this session. Although the bill was introduced in the House, 

it was developed with input and involvement from both House and Senate members 

and their staffs. 

H.R. 2440 reflects several changes made to the original tribal proposal prepared 

in 1999 by the National Steering Committee (NSC). The legislation includes revisions to the 1999 proposal in response to Secretary Thompson’s concerns. I will now 

briefly discuss the most significant changes made in H.R. 2440 that respond to the 

Administration’s concerns about S. 212. 

Qualified Indian Health Program (QIHP). This provision has been removed. The 

NSC designed QIHP as a new provider type through which Indian health programs 

and urban Indian health programs could more fully exercise their statutory authority to receive payments under Medicare, Medicaid and SCHIP. Secretary Thompson 

expressed concern that QIHP was complex and would be administratively burdensome. Tribal leaders acknowledged that the CBO score of this provision—in excess 

of $3 billion over ten years—could be a barrier to Congressional acceptance of QIHP 

and therefore removed it. 

In place of the QIHP proposal, Tribal leaders seek a comprehensive study by the 

Department of Health and Human Services (DHHS) of reimbursement methodologies of Medicare and Medicaid for the Indian Health Service (IHS), Tribal health 

programs, and health programs of urban Indian organizations. The new provision 

found in H.R. 2440 directs the Secretary to perform such a study and report the 

findings to Congress. The Secretary is to examine whether payment amounts under 

current methodologies are sufficient to assure access to care and whether these 

methodologies should be revised consistent with those applicable to the ‘‘most favored’’ providers under the Social Security Act. The current ‘‘all-inclusive’’ rate system through which IHS and tribal hospitals and some clinics now receive Medicare 

and Medicaid reimbursements would remain in place until the Secretary’s recommendations are reported to Congress and Congress decides whether to make any 

changes. 

Extension of 100% Federal Medical Assistance Percentage (FMAP). Tribal leaders 

also agreed to delete a provision that would have extended the 100% FMAP to services provided to Medicaid eligible Indians referred by IHS or tribal programs to outside providers, such as referrals made through the contract health services program. 

Under current interpretation of the Centers for Medicare and Medicaid Services 

(CMS), the 100% FMAP is made available to States only for reimbursements for 

services provided directly in an IHS or tribal facility, even though the only reason 

the patient required care outside the IHS or tribal facility was that the facility could 

not directly provide the service and had to rely on an outside provider. 

While State governments are very supportive of the 100% FMAP expansion, 

DHHS objected that its cost was too high—more than $2 billion over ten years—

and that its financial benefits would flow only to the States, not to Indian health 

programs and their Indian beneficiaries. While the NSC disagrees with the 

44

Department’s interpretation of the statute and their conclusions about the effect of 

the proposed amendment, we agreed to delete the provision from the IHCIA. 

Waiver of Medicare Late Enrollment Penalty. The 1999 tribal proposal (and S. 

212 and S. 556) sought to waive the premium penalty for any Medicare-eligible 

Indian who did not timely enroll in Medicare Part B because of a number of barriers. The DHHS strongly objected to this provision as it would treat Indians differently than other Medicare-eligible persons who do not timely enroll. The DHHS 

asserts that the penalty is needed to encourage eligible persons to enroll and begin 

paying Part B premiums when they first become eligible, rather than waiting until 

they become ill and need to use their Medicare coverage. Tribal leaders also agreed, 

reluctantly, to delete this provision. 

Regulations. Secretary Thompson objected to the tribal leaders’ call for all regulations—including Social Security Act regulations affecting Indian health providers—

to be prepared through Negotiated Rulemaking with tribal representatives. He asserted that the large number and complexity of Social Security Act regulations 

makes negotiated rulemaking unfeasible. In response to this concern, tribal leaders 

eliminated Social Security Act changes from the bill’s negotiated rulemaking provision. 

We believe the changes to the original tribal proposal submitted in 1999 significantly reduce the bill’s federal budget impact. S. 212 (identical to S. 556) was scored 

in 2001 as having a federal budget impact of $6.9 billion over ten years. Deletion 

of the QIHP and the 100% FMAP provisions together reduce the bill’s score by 

about 70 percent. We ask that the Committee submit a request to the Congressional 

Budget Office to either score S. 556 without the above-mentioned provisions, or provide a fiscal budget impact on H.R. 2440. 

Centers for Medicare and Medicaid Services Tribal Technical Advisory Group 

(TTAG) 

At the request of Tribal leaders, the Centers for Medicare and Medicaid Services 

(CMS) established the Tribal Technical Advisory Group (TTAG) to advise CMS on 

Medicare, Medicaid, and Children’s Health Insurance (CHIP) policy issues related 

to American Indians and Alaska Natives. An informal TTAG was formed in 2001 

and consists of Tribal leaders, Area Indian Health Boards, and designated national 

Tribal organizations, including the National Indian Health Board. The activities of 

the TTAG are coordinated primarily through the Intergovernmental and Tribal Affairs Office within CMS. 

The TTAG has forwarded several recommendations to Congress and CMS regarding recommended changes to the reimbursement methodologies in place for the 

Indian Health Service, Tribal health programs, and Urban Indian programs. The informal TTAG is adamant in its position that any reform or changes in the Medicare, 

Medicaid or CHIP programs must allow for Tribal allocation or other direct funding 

mechanisms that authorize Indian health programs access to Centers for Medicare 

& Medicaid Services (CMS) program funding. 

The TTAG has worked closely with the National Steering Committee to develop 

the changes to Title IV of the Indian Health Care Improvement Act that are reflected in H.R. 2440, which are the most recent NSC recommendations. 

Conclusion 

On behalf of the National Indian Health Board, I would like to thank the Committee for its consideration of my testimony and for your diligence in making the 

health of American Indian and Alaska Native people a high priority of the 108th 

Congress. I have been involved with the National Steering Committee since its inception in 1999 and have seen the hard work and compromises that Tribal leaders 

have made. Tribal leaders have come to the table to work out the more contentious 

provisions and we urge the Committee to act swiftly on this important piece of legislation. In order to reduce the terrible disparities between the health of American 

Indians and Alaska Natives compared to other Americans, we need to provide Tribal 

governments and the Indian Health Service with the proper framework to function 

in the most effective and efficient manner. Further, we request that the Committee 

urge the Administration to raise any concerns regarding this legislation in a timely 

manner so that passage of this bill during this session is not jeopardized.

[An attachment to Ms. Davis-Wheeler’s statement follows:]

45

Mr. RENZI. Thank you, Julia. I’m grateful. 

I want to also thank you for recognizing Chairwoman Kathy 

Kitcheyan of the San Carlos Apache tribe, a former teacher and 

real strong leader down there in southern Arizona, as well as nationally, in the health care field. We look forward to her testimony 

tomorrow as it relates to some water issues on the San Carlos reservation. All three of you, thank you so very much for your testimony. 

We’re going to move to a 5-minute question and answer period, 

if you don’t mind. I would like to begin by recognizing the 

gentlelady from the Virgin Islands, Ms. Christensen. 


89608.001
46

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. 

I want to say that on H.R. 2440 you do get two bites at the 

apple. As I said earlier, it’s in our minority health bill, which we 

hope to introduce in the next couple of weeks. I guess I could presume to say that you have the support of all of the other minority 

caucuses in the House. As some of the amendments are incorporated into H.R. 2440, as you are recommending and as everyone 

has pledged to work with you to adopt, those will be incorporated 

as well. 

Co-Chair Wheeler, you had said in your testimony on H.R. 151 

that the elevation to Assistant Secretary of Indian Health should 

be done in a manner which does not diminish the Secretary’s responsibilities to carry out the Federal Government’s trust responsibilities to tribal governments. I just wonder if there is any concern that that elevation could, in any way, undermine the sovereignty of the tribes, moving from the Director into the Department as an Assistant Secretary. 

Ms. DAVIS-WHEELER. There is some concern from tribal governments. I guess the upside to that is that the Director would be 

brought up to the level of Assistant Secretary, but that is why we 

put the comment in the testimony, that the Secretary of DHHS 

still needs to honor those treaties that were signed by all the tribal 

governments. 

Mrs. CHRISTENSEN. Thank you. 

President Hunter, having had some summer fellows who were 

from urban tribes, I know that within all of the disparities in 

health care and the disparities in all services that the tribes face, 

the urban tribes perhaps are more adversely impacted. 

Just speaking to Title I, are you satisfied that there will be improvement in Title I? Is there enough outreach in that to ensure 

that urban tribal members get the outreach and get the scholarships to get into the health professions, or do we need to do something more there? 

Mr. HUNTER. Congresswoman, you used a very interesting 

word—and that word is ‘‘outreach’’—regarding the program. I 

would have to say no, there has not been enough outreach regarding that program’s availability to urban Indians and urban populations. 

For example, just recently I found out that, as part of the package, urban programs are eligible to provide for tuition reimbursement, and we knew that for a while. We have known that we are 

eligible as sites for the placement of scholarships, but we didn’t 

know that there would be additional tuition reimbursement. So I 

have been trying to get that word out. But that probably has been 

in place for some time and we were not aware of it. So I do see 

the need for additional outreach and information coming out of the 

IHS to urban programs regarding Title I and its benefits. 

Mrs. CHRISTENSEN. Thank you. 

I also have a question for President Shirley. In your comments 

on Title I, you say that the Navajo Nation recommends that a 

greater degree of flexibility and autonomy be provided to the 

Indian Health Service tribes and urban Indian health programs to 

implement Title I. I wonder if you could elaborate on what you 

47

mean by the flexibility. What kind of flexibility are you recommending be allowed under the Act? 

Mr. SHIRLEY. What I am alluding to there is more consultation 

with tribes and more input, meaningful input from tribes into the 

legislation and services that are being provided out there in Indian 

country. 

Mrs. CHRISTENSEN. And even the types of health providers perhaps, that the tribe be able to look at what their specific needs are 

and make sure that, within whatever is included in Title I, that 

you have some flexibility to decide what kinds of health providers 

you need and so forth; I would imagine that’s what you’re also referring to. 

Mr. SHIRLEY. That’s exactly right, Congresswoman. 

Mrs. CHRISTENSEN. Thank you. 

Thank you, Mr. Chairman. 

Mr. RENZI. I thank the gentlelady. 

I would like to recognize the gentlelady from the great State of 

California, Ms. Napolitano. 

Mrs. NAPOLITANO. Thank you, Mr. Chairman. 

In my questions and comments to Mr. Michel Lincoln, the 

Deputy Director, do you have any comments on what I was alluding to—mental health assistance, in being able to provide other 

universities access so that the jurisdiction of tribes in those areas 

could be helped? 

Ms. DAVIS-WHEELER. Acting Chairman Renzi, could I respond to 

that? 

Mr. RENZI. Yes, Ma’am. 

Ms. DAVIS-WHEELER. Some of the factors include the lack of opportunity for American Indians and Alaska Natives to receive quality medical education, disproportionate pay for health professions, 

inferior equipment, outdated facilities, and the geographic remoteness of most of our tribal health facilities. Indian country has to 

compete with health providers with governmental facilities that are 

funded at a much higher level, as well as the private sector. It is 

nearly impossible to offer a competitive employment package to potential health professionals without proper incentives. Title I of the 

Indian Health Care Improvement Act provides Indian country with 

the proper tools to employ qualified health professionals. 

One of the other things that I would like to state is that I would 

recommend to this Committee that you work diligently to ensure 

that the Indian Health Service is properly funded to offer competitive pay for health professionals and top rate equipment and facilities, and for them to serve American Indians and Alaska Natives. 

Thank you. 

Mrs. NAPOLITANO. Mr. Chair, one of the things she is saying is 

quite true. I also know that a lot of the women and young people 

need education in math and sciences in order to be able to access 

getting into many of the professions, including the health professions. 

Now, that being said, I don’t know whether that is a focus in 

your schools, or in the schools that are in Native American tribes, 

and whether or not some of the people who are unemployed could 

be helped by giving them additional instructions on math and 

science so as to be able to apply for entry-level health professions, 

48

such as certified nurse assistant, which is right now in dire need 

throughout the United States, which leads into the professions of 

RN, LPN, medical assistant, whatever you want. 

Now, is there any of that being addressed through your services 

or through any of the tribal offices, or the health board, or anybody, because we have a dire need of individuals to be brought up 

to a par that they can participate in entry-level jobs for the medical 

services. Without that, you can try to make available training, but 

if they don’t qualify, you’re going to have to have remedial classes 

for them, whether at the college level or OP or any other institution. 

Ms. DAVIS-WHEELER. Chairman Renzi, I would like to respond to 

that. 

Mr. RENZI. Yes, Ma’am. 

Ms. DAVIS-WHEELER. Congresswoman Napolitano, the National 

Indian Health Board has been working with the National Congress 

of American Indians through a health information systems task 

force, which is addressing exactly what you’re talking about, working with the tribal colleges, getting some computers set up at the 

colleges and at the tribal headquarters, and within the tribal structure, to enhance those people that we have now and bring their 

skills up. 

Also, the National Indian Health Board has been working with 

the American Indian Physicians Association. We had a couple of 

Indian physicians at our conference yesterday that spoke to us 

about the need to collaborate more with them, to get those health 

sciences, math and everything, out to those professions that we 

need. 

Mrs. NAPOLITANO. Thank you, Miss Davis-Wheeler. Not that 

you’re missing the point, but this instruction has got to be begun 

even in the grammar schools. 

Ms. DAVIS-WHEELER. Yes. 

Mrs. NAPOLITANO. By the time you’re in high school, the youngsters are no longer able to get enough instruction to be qualified 

to enter these professions. I would hope that this would be one of 

the things you would look at as you look at the whole ramification 

of not only this bill, but also how to address the issue with every 

tribe, because I’m sure everybody has the same problem. It isn’t 

just one tribe or one State. It is generic. Everybody has the same 

problem. 

So how do we address that by beginning to help, to either fund 

it or address it in the education system, to address it into the medical system. 

Thank you, Mr. Chair. 

Ms. DAVIS-WHEELER. A point well taken, and we will as a Board 

look at that very closely. Thank you. 

Mr. RENZI. The gentleman from New Mexico. 

Mr. TOM UDALL. Thank you, Chairman Renzi. 

Let me say to Chairman Renzi, he and I share the Navajo Nation 

in our two Congressional Districts, and we work very closely together on these issues. We look forward to doing so in the future. 

It is wonderful, President Shirley, to have you here today representing the wonderful Navajo Nation. I think you have made a 

very strong statement. In particular, I’m looking at the Navajo area 

49

health service and the successes you have had. It is really a 

wonderful thing to see when the Navajo people are doing better 

than the general U.S. population in cancer deaths, particularly 

breast cancer, heart disease deaths, low weight births. I mean, 

those are some real successes and you should be very proud of 

those. 

One of the things that you do highlight is what we spend on 

health care services. The treaty that the U.S. Government entered 

into with the Navajo Nation talked about providing good, highquality health care. When you have numbers where the Indian 

Health Service is spending a little over a thousand dollars a person, and the average is close to $3,500 a person, clearly there are 

problems there. 

Could you tell us the position of the Navajo Nation in terms of 

how you think it would change if we had the health care dollars 

up to the amount that the average is, and what difference that 

would make in terms of health care on the Navajo Nation? 

Mr. SHIRLEY. Congressman Udall, I think what it would mean is 

more health care professionals being there on Navajo land delivering health care services to Navajo people, and not only to Navajo 

people but all Native Americans that are within the Navajo Nation 

boundaries. In terms of giving dollars to Native Americans, there 

would be facilities not as far off. I earlier alluded to bad dirt roads 

as being one of our problems. If there could be more dollars, there 

would be more facilities out there with health care professionals to 

where they are more locally accessible. I think that’s what it 

means. If we can have sufficient funding, adequate funding, we will 

have better health care delivery services on Navajo land. 

Mr. TOM UDALL. Thank you. 

One of the parts of this—and you mentioned it, and you just alluded to it now—is Title I, which has the purpose of really trying 

to get young Native Americans educated in health care fields and 

being able to return to the reservation, return to the Navajo Nation 

and work with their community and up the level of health care. We 

haven’t seen the successes that we should in that particular area. 

I like the idea that you put in here of saying we need to do more, 

we do more of an increase in that area. So anything that you can 

tell us that would move us along in terms of getting more young 

Native Americans into health care education fields, we would be 

happy to hear it on this Committee. 

Now, you mentioned Title II. You and I have worked, and I know 

Chairman Renzi knows about this, with the Navajo uranium miners. The mining on the reservation has just been devastating to the 

Navajo people. We have created a program in order to compensate 

Navajo miners who have died of lung cancer and many other kinds 

of cancer. But there is still a lot of suspicion out there that this 

is more widely dispersed than just people that went into the mines, 

that the families may have been impacted. 

What you have called for here under Title II is a section for 

studying and monitoring programs to monitor the trends. One of 

the areas is the families. As you well know, these Navajo families 

that had a miner and the miner came home and had the mining 

dust and uranium on their clothes, and brought rocks in, not knowVerDate 0ct 09 2002 13:22 Mar 26, 2004 Jkt 088533 PO 00000 Frm 00053 Fmt 6633 Sfmt 6602 J:\DOCS\89608.TXT HRESOUR1 PsN: KATHY
50

ing that they were dangerous and had uranium in them, they need 

to be monitored. 

I think that’s what you’re talking about in a general way, isn’t 

it, that there are a lot of suspicions in terms of all of the mining, 

and we just need to be able to assure people that we are monitoring their health and following this situation? 

Mr. SHIRLEY. Exactly, Congressman. I would point out, too, the 

points awarded to the different afflictions that are caused by uranium radiation I think needs to be re-looked at. Before compensation can be had, the Federal Government says you have to have a 

certain amount of points before that can happen. But there are 

members of my people out there and families where they were also 

afflicted by the uranium and radiation but are being told they are 

not eligible. I think that needs to be relooked at. 

That’s where I bring out the point that a lot of what’s going on 

in Native country in trying to get compensation to those miners 

who were afflicted and the families who were afflicted needs to be 

revisited. 

Mr. TOM UDALL. Thank you, President Shirley. I see my time is 

up. 

I just want to tell you, please let Congressman Renzi and myself 

know, as we move along with this legislation, if there are other 

changes that you see and if there are things that pop up that you 

didn’t realize now are going to be detrimental to the Navajo Nation, we want to help with them. 

I have another commitment and I won’t be able to stay for the 

full hearing, but I thank you very much for your leadership, and 

your presence here is really setting a very high standard in the 

early months of that presidency. 

Thank you, Chairman Renzi. 

Mr. SHIRLEY. Thank you, Congressman. 

Mr. RENZI. I want to thank Congressman Udall. He speaks the 

truth when he talks about a partnership and the friendship that 

exists between the two of us to work together. I’m thankful for his 

leadership and some of his mentorship that he has shown me in 

being a new Congressman. I appreciate that, sir. 

Many may not expect it—I know Mr. Hunter probably knows the 

next gentleman—but one of the best fighters for Native American 

rights and issues comes from the State of New Jersey, of all places. 

The gentleman from New Jersey. 

Mr. PALLONE. Thank you. Is that comment partially based on the 

fact that you are from Long Branch, NJ too? 

[Laughter.] 

I shouldn’t say that. 

Mr. RENZI. I was born there. But I’m an Arizonan, remember? 

Mr. PALLONE. I know. I know. I appreciate what the gentleman 

said, though. Thank you. 

I wanted to ask Miss Davis-Wheeler. You know, I agree with you 

100 percent, that the main goal here in the Committee and in the 

House in general is to try to get this bill passed and moved as soon 

as possible, because it has been a number of years now since the 

National Steering Committee put this together, and I know there 

have been some changes. But given that we do have a crisis, or I 

think we do have a crisis with regard to the Indian Health Service 

51

and Indian health care, it is important to move the bill, and we all 

share that. 

You mention in your written testimony that you had tried to address some of the concerns that had been raised in the past about 

the legislation. I think it was primarily the cost, because I know 

in the last session, when we were going around and trying to get 

a hearing here, many of the members said this is very costly. I 

know that the bill that has been introduced now is somewhat different. 

Could you maybe summarize that in a way, because I think it’s 

important in terms of our ability to get it moved, to talk a bit about 

the changes that have been made to address the cost, overall cost. 

Ms. DAVIS-WHEELER. Yes, thank you, Congressman Pallone. 

Well, since the passage of the Indian Health Care Improvement 

Act in 1976, Medicare and Medicaid payments have become vital 

sources of revenue for basic tribal hospital and clinic operations. In 

Fiscal Year 2002 alone, IHS and tribally operated hospitals and 

clinics collected $460 million for services provided to Indian people 

enrolled in these programs. This amount enhances the resources 

available for the IHS hospitals and clinics budget by nearly 30 percent. 

In order to further improve the ability of the Indian health providers to access third party resources, the National Steering Committee developed several changes to the Title IV that were included 

in S. 212 during the 107th Congress. 

When asked to respond to the language contained in S. 212, several concerns were raised by the Health and Human Services Secretary, Tommy Thompson, regarding the proposed changes in Title 

IV. The concerns were primarily related to costs. 

I would like to note that S. 556, introduced during this Congress, 

is identical to S. 212 and, therefore, many of the concerns raised 

in regards to S. 212 still remain. 

In response to the National Steering Committee revising their 

recommendations for the reauthorization, I think it was quite helpful to hold the joint House Resources Committee and Senate Committee on Indian Affairs hearing that was held in July. This was 

developed with input and the involvement of both House and Senate members and their staff. 

I don’t know if that adequately answers your question regarding 

the costs, but I know Title I has been looked at very closely by our 

National Steering Committee members. 

Mr. PALLONE. Thank you. 

I know a part of this has already been asked, and it’s kind of a 

broad question, but to President Shirley, in terms of Title I, the 

problem in terms of not having enough health professionals, Native 

American or not, just addressing Indian country, particularly in the 

more remote areas—I will look at it from a threefold question. I 

asked this before. 

Is the problem that a lot of people have difficulty in gaining entrance to nursing schools or medical schools, or is it that they can’t 

afford it and we need more scholarships? Or is the problem the 

third thing, maybe they take advantage of these scholarship programs and they serve in Indian country for a few years, but then 

don’t stay and move on to another area? 

52

I know that the numbers have not really increased much in the 

last few years, so obviously in Title I we’re trying to address that. 

But if you could just talk about maybe those various stages. 

Mr. SHIRLEY. Thank you, Congressman. 

Well, I think one of the problems on the upper Navajo land is 

that the Navajo Nation, as a government, has never made education its priority. It has always been down to the number eight, 

nine, ten, in there somewhere. But this time around, through my 

administration, the Navajo Nation as a whole nation and as a government has never had education as its number one priority. So 

why we aren’t having enough people going into the health professions is one of the things we are looking at. 

The biggest problem we have in getting people into the health 

professions, as well as the other professions, is the lack of scholarships. If the Committee here, and the Congress and the Senate can 

adequate fund the scholarship program within the Indian Health 

Service bill, that would go a long ways toward helping us to move 

with our people toward getting them into the health professions. 

A lot of our students aren’t having problems getting into the universities or colleges. That’s not a problem. They get themselves eligible and they get admitted, but then they go looking for scholarships and it’s not there. The Navajo Nation at this point in time 

is doing what it can to fund as many of its members as it can to 

try to encourage them to go to higher learning. 

The other thing, too, is that we like to graduate more doctors, 

nurses, dentists, but there needs to be a guarantee put into where, 

when they graduate and get their doctor’s degree or a medical 

degree, they need to return to Navajo land and to Indian country 

to give service to the people. There needs to be a mechanism put 

in to where that will happen. Of course, like I said, for the Navajo 

Nation, education is our number one priority. We are looking at 

mechanisms just like that, Congressman. 

Thank you. 

Mr. PALLONE. Thank you. 

Thank you, Mr. Chairman. 

Mr. RENZI. I thank the gentleman. 

Last week we passed a land exchange that helped the Eastern 

Band of Cherokee, and this next gentleman was absolutely key in 

making sure we got it through. He worked across both aisles, 

Democrats and Republicans coming together. 

I’ll tell you, personally, I have had a chance to work with him 

and develop a friendship. If I was going into battle, I would want 

him on my side. So I want to thank the gentleman from California, 

Mr. Baca, for being here today. I will shift to him for his questions. 

Mr. BACA. Thank you very much, Mr. Chairman, and thanks for 

your concern for Native Americans as well. And I’m not from New 

Jersey. As he stated, I’m from California and not from Arizona. 

One of my questions would be that we’re all very much concerned 

with improving the quality of life, especially in the health professions. I do agree with Ms. Davis-Wheeler, that we really need to 

put in a lot more funding. If we really want parity, and if we look 

at sovereign countries as well, we must have that same opportunity 

that others have. There seems to be a lack of funding when it 

comes to sovereignty and sovereign countries. 

53

One of the things we have to do is make sure that in order for 

health services to be provided, funding has got to be equal, because 

you can’t provide the health services where a lot of our reservations 

are also growing and our needs are also growing in the health field, 

especially if you look at diabetes. Diabetes and type II diabetes in 

the area is very important, so we need to develop not only the educational programs, but are the educational programs there right 

now, and if not, what kind of educational programs do we need to 

develop and what additional funding do we need to provide, especially as diabetes affects many of our Native Americans compared 

to others. I know that Hispanics are very high in type II. 

What can be done in these areas? 

Ms. DAVIS-WHEELER. Congressman Baca, I am very glad that 

you asked that question. I’m just returning from Hawaii. I attended a meeting over there a week before last and met with the 

Native Hawaiians. The Native Hawaiians have a high rate of diabetes, just as much as Native Americans. 

I met with a man who was a teacher of the Hawaiian language, 

and he was an amputee. He spoke about the lack of funding that 

we, as indigenous people, have to address the diseases that we 

have. I couldn’t help but look at him, and I tried to avert my eyes 

to not stare, but you could tell that he was suffering from this disease. 

One of the things that the National Indian Health Board and the 

National Congress of American Indians is looking at is maximizing 

that money, the diabetes money that has been appropriated by 

Congress, through I would like to say the leadership of Congressman Nethercutt—and he was here earlier and spoke to the bill that 

would elevate the Director. I went outside in the hallway to speak 

to him because I really wanted him to know, as a tribal leader, 

that we appreciate his efforts in what he’s doing. 

My recommendation to this Committee would be the continuation 

of the appropriation for diabetes to the Native American governments, whether it be through the Indian Health Service or to the 

Indian governments themselves. I have seen an increase of awareness, the prevention education programs that have been developed 

by the different tribes across the United States, and I think we 

should get the appropriations increased. 

There was a question earlier about how much more do we need. 

I think that $2.4 billion is not very much to ask for to increase the 

Indian Health Service budget to enhance the health professions 

and the other areas that we need to look at. 

Thank you. 

Mr. BACA. I agree with you. I don’t think it’s enough, because 

when you look at the prevention programs and others that actually 

improve the quality of life, in order for the quality of life to improve 

you have to be able to provide the services that are there. It is difficult, even from the point of recruitment, if you’re looking at scholarships—we have many of our students going on—but you also 

want to make it competitive in terms of salary. So if you’re trying 

to draw them back into the reservations, you have to have the 

competitive salaries. Otherwise, they’re going to go somewhere else. 

They get educated and they’re working in some other health field. 

54

I also agree that we’ve got to do a better job in making sure that 

we’re competitive in terms of salaries to attract our Native Americans who are going on to school to come back; isn’t that correct? 

Ms. DAVIS-WHEELER. That’s correct. 

Chairman Renzi, if I may also add, the Indian Health Service is 

not tax-exempt for its scholarship benefits. That is one thing that 

I think needs to be looked at. The scholarship program that the 

Indian Health Service has really needs a boost to get those students to come, and that tax-exempt benefit would assist a lot. 

Mr. BACA. One final question, Mr. Chair, if I can. I know my 

time has run out. 

Do you believe the changes in the duties of the Director of the 

Indian Health Service to the new Assistant Secretary for Indian 

Health, is that a way to improve the trust responsibility or not? Do 

you think this new change is positive based on H.R. 151? 

Ms. DAVIS-WHEELER. Congressman Baca, I think that it would 

enhance us, as tribal governments, to be accessible to other agencies within the DHHS. It would also give that recognition to us as 

Native American tribes to those other areas across the United 

States that are receiving funding and that we are not receiving 

funding for. So I think elevating the Director up to the Assistant 

Secretary level would be excellent in terms of getting that information out to the other Federal agencies. 

Mr. SHIRLEY. Congressman Renzi, if I can answer the last question? 

Mr. RENZI. Go ahead, Mr. President. 

Mr. SHIRLEY. I think the elevation of the Director to Assistant 

Secretary position, what it would do for Native Americans and the 

Navajo Nation is that we like to work with people who have the 

authority to make decisions. Right now, we’re having to go through 

the bureaucracy and the red tape of trying to get answers. I think 

if we can have inside access to an Assistant Secretary position, who 

has the authority to make decisions, it will make the services of the 

delivery system much better. 

And then if you can allow the Native nations to work with an 

Assistant Secretary position, along with the Secretary position, 

you’re honoring the tribes and Native Americans, also. 

Mr. BACA. Right. And you would have accountability as well. 

That’s part of it, too, right? 

Mr. SHIRLEY. Exactly. 

Ms. DAVIS-WHEELER. Right. 

Mr. BACA. Thank you very much. 

Mr. RENZI. I thank the gentleman from California. 

I just have a few questions and then we’ll wrap up. Julia, I really 

am grateful for the teachings that you share here today. You went 

to the issue of the tax-exempt status. Congress has set aside legislation, or has created legislation, that exempts the National Health 

Service Corporation, as well as the Department of Defense, on their 

scholarship benefits. 

If we were able to provide a tax-exempt status for IHS scholarships, what kind of figures do you think we’re looking at? How big 

is the program right now? I guess we could start there. 

Ms. DAVIS-WHEELER. Wow. How big is the program? 

55

Mr. RENZI. On the scholarship side. It’s OK. I didn’t mean to 

stump you. What I’m looking for is, we really need to provide that 

same kind of equality—is Joe Shirley helping? 

Ms. DAVIS-WHEELER. Yes. We have a chart here, the Indian 

Health Service Scholarship Program. The total IHS scholarship 

awards are 8,716 this year. 

Mr. RENZI. Different scholarships? That many students, President Shirley? 

Ms. DAVIS-WHEELER. Yes. 

Mr. RENZI. So if we can achieve that kind of a tax status, it’s a 

major benefit that will help close to 10,000 students and families. 

It’s time, I think. We will look forward to pushing ahead on that. 

Ms. DAVIS-WHEELER. If I may add, we will get information from 

the National Indian Health Board and we will send that in to you, 

too. 

Mr. RENZI. That would be great. Thank you. 

Mr. Hunter, I want to thank you for your testimony. It was interesting how you articulated and pointed out the definitions and how 

it affects all the way through on the different titles. I appreciate 

that research and depth of effort you provided to us. 

I really didn’t get a chance to get a depth of feeling on the national programs, and you spoke about the underfunding for some 

of the national programs. Could you give me maybe the top three 

national programs that you would like to see fully funded, or where 

those national programs would go if we had the proper funding behind it? 

Mr. HUNTER. That is a difficult question to answer. We did in our 

preparations for consultation on the Fiscal Year 2005 budget come 

up with 19 priority areas that were considered, that covered both 

health care areas and facilities and construction. 

It’s difficult to say. Even though the priorities were not 

prioritized, I think amongst the top ones would be diabetes, alcoholism and behavioral health. I would say the third, again not to 

exclude other health care priorities, would be facilities. We have to 

get more money into facilities at urban programs. We don’t have 

access to those benefits right now. 

Mr. RENZI. You do a good job of outlining, and then your vision 

of where we need to go with the priorities. I’m grateful. 

Mr. HUNTER. Thank you. 

Mr. RENZI. President Shirley, thank you for coming all this way. 

It’s good to have a friend and brother here. I’m grateful for your 

testimony. 

You compassionately spoke about the dirt roads and the contribution that makes to respiratory and poor health. You spoke of 

the lack of communication and the inability to respond properly. I 

thought you were very articulate when it came to the nursing and 

dental shortages, not only in your testimony but in answering the 

questions. I need you to teach me now as a friend. 

On section 216 you talked about Arizona as a contract area. Can 

you tell me a little more about that? 

Mr. SHIRLEY. I believe that’s a provision in the legislation that 

allows the whole State of Arizona as a contract health services delivery system, but that has never been adequately funded. If that 

could be fully funded, I think it would deliver more services to 

56

Navajos out there and in the urban areas. We find Navajos, you 

know, in all the counties. 

Mr. RENZI. True. 

Mr. SHIRLEY. And not only Navajos, but also Native Americans, 

the federally recognized tribes living in the State of Arizona. Many 

of them are not living on their own Native land, so when they go 

off the land, they need to have a plug into the health services facilities in the urban metropolitan areas. If the contract services provision for the whole State of Arizona is fully funded, Navajos living 

off Navajo land would then have access to quality health care services throughout the State. 

Mr. RENZI. Thank you, Mr. President. 

Is there anything else any of the witnesses would like to share? 

Is there anything in your hearts that didn’t come out today during 

the testimony? 

Mr. Shirley. 

Mr. SHIRLEY. Congressman Renzi, I would like to give input or 

respond to the question you posed to Miss Wheeler regarding what 

are our priorities. 

On the whole, I would say manpower training. That’s why these 

scholarships should be given an adequate amount of money for 

health professions is very important. Again, like you said, we need 

built-in mechanisms where the return to Native country is guaranteed. I think one Congressman said we need comparable salaries. 

That is very important. 

The second one would be the prevention aspects of health care 

delivery systems in Native country. In our case, the diabetes program is really working and we appreciate the Congress and U.S. 

Government for funding prevention programs for diabetes. That 

certainly should continue, to put money into prevention. 

The third one that we would zero in on is behavior health services. Of course, we have substance abuse, much of it alcohol, that 

is very pervasive throughout Navajo land. We’re trying to do the 

best we can to arrest the problem. If more moneys could be had for 

our behavior health services program to address substance abuse, 

that would go a long ways toward helping us alleviate the alcoholism culprit. 

Thank you, Congressman. 

Mr. RENZI. Well said. 

Mr. Hunter. 

Mr. HUNTER. If I may, thank you. 

I think one of the things that is most important is that when we 

come to Congress every year and we’re looking at the budget, we’re 

identifying that additional funding is needed. Very often I think to 

myself, well, where are we going to get that money? Well, in the 

past I proposed that taxes be increased but that doesn’t go over 

very well. 

I think one of the solutions that could be proposed, particularly 

within our social services programs, would be something called ‘‘social entrepreneurship.’’ We at NCUIH fully support and recognize 

tribal sovereignty. We completely support the recognition of the 

Federal Government’s trust responsibility for Native Americans, 

and we also recognize that we must also help ourselves. So if 

within our social programs we are able to generate funds that can 

57

be devoted and turned back into those programs so that we are 

more self-sufficient at expanding health care services, I think it 

will be a great step in the right direction. 

Mr. RENZI. So social entrepreneurship is profit centers within the 

health arena? 

Mr. HUNTER. I’m sorry? 

Mr. RENZI. Social entrepreneurship is essentially a profit center, 

making a profit within the health arena, profitable clinics or whatever? 

Mr. HUNTER. Right. For example, one project that we’re interested in working on at AICH in New York is when we sponsor conferences and workshops, particularly since we are responsible to 

outreach to non-Native providers of health care and educate them 

to developing our education program so that we can offer education 

units that are recognized by nursing and other professions, so that 

we can develop or charge the people for taking those education programs and support our programs. 

Mr. RENZI. That’s creative. Thank you, Mr. Hunter. 

Mr. HUNTER. Thank you. 

Mr. RENZI. Julia, you get to finish. 

Ms. DAVIS-WHEELER. Thank you. 

First of all, I would like to tell you that, as a policy person for 

my tribe, it is an honor to sit here and testify in front of the 

Committee. I appreciate the time that you have made. 

I really would like to say that honoring the treaties that all of 

us have signed as American Indians, Alaska Natives, is the utmost 

in my mind. Having just come in last night from the conference 

and listening to the comments and remarks made at the conference, health is just one component of the treaty. We have education, land, water, et cetera. 

But the vision I would like to see, and speaking here today for 

the National Indian Health Board, is to see that our people have 

adequate health care for our people at home. The ones who are 

there that can’t speak, we are here for them. The ones that can’t 

walk, we’re here for them. It really means a lot to me, and I know 

my colleagues here on the panel feel the same way. 

The appropriate funding for us as American Indians and Alaska 

Natives has to come up to the level of the general population. So 

giving us this time to come in and speak was excellent. I would like 

to encourage the Committee to have more hearings, and if there is 

any way that we can help as the National Indian Health Board, we 

will put that effort forward. 

Thank you. 

Mr. RENZI. The words are nice, but we have got to deliver. I 

think that’s your message. 

I want to thank all the witnesses for your valuable testimony, 

particularly to the members for their questions. The members of 

this Committee may have additional questions for the witnesses, 

and we will ask that you respond to these in writing. The hearing 

record will remain open for these responses. 

If there is no further business, we again thank our valuable witnesses and the Committee stands adjourned. 

[Whereupon, at 12:30 p.m., the Committee was adjourned.] 

[The prepared statement of Mr. Tom Udall follows:]

58

Statement of The Honorable Tom Udall, a Representative in Congress from 

the State of New Mexico, on H.R. 2440

Mr. Chairman, thank you for holding this hearing today to discuss the reauthorization of the Indian Health Care Improvement Act (IHCIA). 

Created in the spirit of the United States’ trust duties, the IHCIA has become an 

essential element of the health and welfare of American Indian communities. It is 

the primary federal statute that establishes the structure for operation of health 

programs for American Indians and Alaska Natives by the Indian Health Service 

(IHS). 

The chronic under-funding of the IHS has severe ramifications on the Indian population. Tuberculosis, cardiovascular disease, alcoholism, SIDS, fetal alcohol syndrome, and, increasingly, AIDS, plague America’s Native communities at incidence 

rates far greater than for other Americans. Diabetes is especially prevalent in these 

communities. 

I am acutely aware of the diabetes problem, both in New Mexico, the state I represent, and across the nation. According to a recent 2002 health audit from the 

Navajo Area Indian Health Service, there are 15,805 patients on its diabetes registry, out of a total 180,462 population. 

Similarly, the Pueblo of Santo Domingo in New Mexico reports that since 1997, 

there was a 105% increase in diabetes patients, and an increase of 1038% in patients categorized as needing assistance with chronic diseases. 

In addressing the diabetes epidemic, I believe we should strongly emphasis prevention and education. It is far better to tackle this disease up front with prevention 

and education rather than at the tail end, during end-stage renal disease and dialysis treatments, where enormous expense is involved and quality of life and health 

of the individual cannot be ensured. 

Although Congress and the President recently acknowledged the severity of diabetes among Native Americans by providing historic funding for prevention and treatment programs, I believe we must increase our commitment in order to take advantage of the unprecedented scientific opportunities we have for advances leading to 

better treatments, a means of prevention and, ultimately, a cure for this devastating 

disease. 

As such, I strongly support the reauthorization of the Indian Health Care Improvement Act so that we may continue to address the healthcare needs of Indian 

communities. 

Thank you.

Æ